- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $934.88 / $934.88 / $1,168.58
| Professional | | $934.88 | $934.88 | $1,168.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.00 / $328.89 / $607.26
| Facility | | $1.00 | $328.89 | $607.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.00 / $719.47 / $1,909.35
| Professional | | $524.00 | $719.47 | $1,909.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $310.42 / $607.26 / $3,577.26
| Facility | | $310.42 | $607.26 | $3,577.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.89 / $551.32 / $1,272.90
| Professional | | $328.89 | $551.32 | $1,272.90 |