- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.59 / $436.52 / $1,000.00
| Professional | | $323.59 | $436.52 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $691.83 / $794.33
| Professional | | $588.84 | $691.83 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $630.96 / $831.76
| Professional | | $467.74 | $630.96 | $831.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $2,754.23 / $10,471.29
| Facility | | $2,630.27 | $2,754.23 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $776.25 / $1,318.26
| Professional | | $436.52 | $776.25 | $1,318.26 |