- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $130.46 / $485.00 / $573.00
| Professional | | $130.46 | $485.00 | $573.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,849.67 / $2,849.67 / $3,539.44
| Facility | | $2,849.67 | $2,849.67 | $3,539.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.37 / $144.37 / $471.12
| Professional | | $144.37 | $144.37 | $471.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.80 / $226.65 / $471.12
| Professional | | $116.80 | $226.65 | $471.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.52 / $226.65 / $471.12
| Professional | | $187.52 | $226.65 | $471.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.54 / $207.71 / $578.25
| Professional | | $167.54 | $207.71 | $578.25 |