- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $134.90 / $186.21
| Professional | | $100.00 | $134.90 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,548.82 / $1,548.82 / $1,995.26
| Facility | | $1,548.82 | $1,548.82 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,318.26
| Facility | | $1,318.26 | $1,318.26 | $1,318.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $141.25 / $199.53 / $436.52
| Professional | | $141.25 | $199.53 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $616.60 / $616.60 / $616.60
| Professional | | $616.60 | $616.60 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $134.90 / $194.98 / $331.13
| Professional | | $134.90 | $194.98 | $331.13 |