- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $746.22 / $746.22 / $932.78
| Professional | | $746.22 | $746.22 | $932.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,616.95 / $3,616.95 / $3,616.95
| Facility | | $3,616.95 | $3,616.95 | $3,616.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.00 / $1,703.26 / $1,703.26
| Professional | | $525.00 | $1,703.26 | $1,703.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $399.06 / $399.06 / $657.66
| Facility | | $399.06 | $399.06 | $657.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $399.06 / $624.02 / $711.93
| Professional | | $399.06 | $624.02 | $711.93 |