- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $338.84 / $707.95
| Professional | | $281.84 | $338.84 | $707.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $251.19 / $251.19 / $251.19
| Facility | | $251.19 | $251.19 | $251.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $891.25 / $1,000.00
| Professional | | $588.84 | $891.25 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $575.44 / $977.24
| Professional | | $338.84 | $575.44 | $977.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $295.12 / $3,090.30
| Facility | | $204.17 | $295.12 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $575.44 / $1,122.02
| Professional | | $316.23 | $575.44 | $1,122.02 |