- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $541.92 / $956.34 / $1,346.16
| Professional | | $541.92 | $956.34 | $1,346.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,462.38 / $1,462.38 / $1,462.38
| Facility | | $1,462.38 | $1,462.38 | $1,462.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $691.34 / $1,232.30 / $2,564.06
| Professional | | $691.34 | $1,232.30 | $2,564.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $200.00 / $221.39
| Professional | | $100.00 | $200.00 | $221.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.39 / $188.39 / $251.18
| Professional | | $188.39 | $188.39 | $251.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $547.66 / $744.02 / $1,240.04
| Professional | | $547.66 | $744.02 | $1,240.04 |