- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $420.00 / $744.00 / $3,858.00
| Professional | | $420.00 | $744.00 | $3,858.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,004.25 / $1,004.25 / $1,004.25
| Facility | | $1,004.25 | $1,004.25 | $1,004.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.85 / $679.66 / $1,348.48
| Professional | | $285.85 | $679.66 | $1,348.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,004.25 / $1,004.25 / $1,004.25
| Facility | | $1,004.25 | $1,004.25 | $1,004.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.85 / $679.66 / $1,348.48
| Professional | | $285.85 | $679.66 | $1,348.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.08 / $600.70 / $1,386.24
| Professional | | $262.08 | $600.70 | $1,386.24 |