- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $96.47 / $249.84 / $1,030.00
| Professional | | $96.47 | $249.84 | $1,030.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,016.34 / $3,016.34 / $3,336.14
| Facility | | $3,016.34 | $3,016.34 | $3,336.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.52 / $340.52 / $889.89
| Professional | | $340.52 | $340.52 | $889.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.06 / $228.38 / $889.89
| Professional | | $141.06 | $228.38 | $889.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $166.68 / $403.02 / $889.89
| Professional | | $166.68 | $403.02 | $889.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $349.52 / $389.31 / $1,092.24
| Professional | | $349.52 | $389.31 | $1,092.24 |