- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.63 / $794.33 / $912.01
| Professional | | $478.63 | $794.33 | $912.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.12 / $50.12 / $50.12
| Professional | | $50.12 | $50.12 | $50.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $758.58 / $758.58
| Professional | | $758.58 | $758.58 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $295.12 / $1,000.00
| Professional | | $295.12 | $295.12 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $40.74 / $81.28 / $812.83
| Facility | | $40.74 | $81.28 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $812.83 / $1,659.59
| Professional | | $309.03 | $812.83 | $1,659.59 |