- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $419.44 / $453.93 / $3,858.00
| Professional | | $419.44 | $453.93 | $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
- $824.91 / $906.53 / $1,348.48
| Professional | | $824.91 | $906.53 | $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
- $220.00 / $906.53 / $1,348.48
| Professional | | $220.00 | $906.53 | $1,348.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.08 / $600.70 / $2,700.00
| Professional | | $262.08 | $600.70 | $2,700.00 |