- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $879.08 / $879.08 / $3,221.72
| Professional | | $879.08 | $879.08 | $3,221.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $670.25 / $670.25 / $897.30
| Facility | | $670.25 | $670.25 | $897.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $569.71 / $670.25 / $1,149.75
| Professional | | $569.71 | $670.25 | $1,149.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $60.00
| Professional | | $60.00 | $60.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $494.48 / $604.37 / $1,098.84
| Professional | | $494.48 | $604.37 | $1,098.84 |