- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $362.04 / $405.86 / $508.97
| Professional | | $362.04 | $405.86 | $508.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $252.00 / $252.00 / $252.00
| Facility | | $252.00 | $252.00 | $252.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $702.00 / $766.00 / $1,159.00
| Professional | | $702.00 | $766.00 | $1,159.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $463.11 / $722.85 / $1,125.19
| Professional | | $463.11 | $722.85 | $1,125.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.00 / $293.00 / $3,239.00
| Facility | | $293.00 | $293.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.54 / $759.22 / $1,209.01
| Professional | | $411.54 | $759.22 | $1,209.01 |