- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.82 / $650.91 / $1,624.00
| Professional | | $436.82 | $650.91 | $1,624.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $106.83 / $438.51 / $612.62
| Facility | | $106.83 | $438.51 | $612.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Professional | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $383.60 / $435.30 / $467.70
| Professional | | $383.60 | $435.30 | $467.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $659.02 / $1,185.80 / $1,185.80
| Facility | | $659.02 | $1,185.80 | $1,185.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,208.00 / $2,208.00 / $2,208.00
| Professional | | $2,208.00 | $2,208.00 | $2,208.00 |