- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.32 / $435.35 / $1,045.60
| Professional | | $120.32 | $435.35 | $1,045.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $326.00 / $326.00 / $326.00
| Facility | | $326.00 | $326.00 | $326.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.39 / $326.00 / $489.80
| Professional | | $293.39 | $326.00 | $489.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $120.32 / $326.00 / $1,045.60
| Facility | | $120.32 | $326.00 | $1,045.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.00 / $326.00 / $732.55
| Professional | | $326.00 | $326.00 | $732.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.47 / $1,129.19 / $1,698.23
| Professional | | $1,096.47 | $1,129.19 | $1,698.23 |