- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,227.04 / $1,303.44 / $1,507.00
| Professional | | $1,227.04 | $1,303.44 | $1,507.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $161.94 / $635.83 / $1,059.52
| Facility | | $161.94 | $635.83 | $1,059.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,227.04 / $1,507.00 / $2,878.37
| Facility | | $1,227.04 | $1,507.00 | $2,878.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $673.65 / $673.65 / $673.65
| Facility | | $673.65 | $673.65 | $673.65 |