- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $750.30 / $750.30 / $1,545.80
| Professional | | $750.30 | $750.30 | $1,545.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,724.00 / $1,724.00 / $1,724.00
| Facility | | $1,724.00 | $1,724.00 | $1,724.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,724.00 / $1,724.00 / $1,724.00
| Professional | | $1,724.00 | $1,724.00 | $1,724.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.11 / $93.11 / $109.54
| Professional | | $93.11 | $93.11 | $109.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.66 / $112.76 / $811.01
| Professional | | $67.66 | $112.76 | $811.01 |