- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,116.00 / $1,182.96 / $1,395.00
| Professional | | $1,116.00 | $1,182.96 | $1,395.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $150.00
| Professional | | $150.00 | $150.00 | $150.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $478.51 / $478.51 / $1,378.16
| Facility | | $478.51 | $478.51 | $1,378.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.41 / $2,588.32 / $2,588.32
| Professional | | $230.41 | $2,588.32 | $2,588.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $343.17 / $478.51 / $478.51
| Facility | | $343.17 | $478.51 | $478.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.41 / $434.60 / $478.51
| Professional | | $230.41 | $434.60 | $478.51 |