- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $489.78 / $891.25
| Professional | | $338.84 | $489.78 | $891.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $588.84 / $1,000.00
| Professional | | $354.81 | $588.84 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $691.83
| Facility | | $616.60 | $616.60 | $691.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.84 / $602.56 / $1,148.15
| Professional | | $338.84 | $602.56 | $1,148.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.68 / $812.83 / $1,513.56
| Professional | | $446.68 | $812.83 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $616.60 / $1,288.25
| Professional | | $354.81 | $616.60 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $602.56 / $1,122.02
| Professional | | $371.54 | $602.56 | $1,122.02 |