- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.98 / $850.00 / $4,127.10
| Professional | | $200.98 | $850.00 | $4,127.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,074.29 / $1,074.29 / $1,074.29
| Facility | | $1,074.29 | $1,074.29 | $1,074.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $395.46 / $434.07 / $1,441.73
| Professional | | $395.46 | $434.07 | $1,441.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,074.29 / $1,074.29 / $1,074.29
| Facility | | $1,074.29 | $1,074.29 | $1,074.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $395.46 / $434.07 / $1,441.73
| Professional | | $395.46 | $434.07 | $1,441.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.70 / $402.96 / $1,482.93
| Professional | | $172.70 | $402.96 | $1,482.93 |