- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $316.23 / $537.03
| Professional | | $281.84 | $316.23 | $537.03 |
- 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
- $630.96 / $954.99 / $1,000.00
| Professional | | $630.96 | $954.99 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $575.44 / $977.24
| Professional | | $331.13 | $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
- $309.03 / $575.44 / $1,096.48
| Professional | | $309.03 | $575.44 | $1,096.48 |