- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $562.34 / $1,000.00
| Professional | | $562.34 | $562.34 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $776.25 / $776.25
| Facility | | $776.25 | $776.25 | $776.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.62 / $426.58 / $676.08
| Professional | | $77.62 | $426.58 | $676.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,548.82 / $1,548.82
| Professional | | $1,479.11 | $1,548.82 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $79.43 / $79.43
| Professional | | $79.43 | $79.43 | $79.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.23 / $416.87 / $758.58
| Facility | | $56.23 | $416.87 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $426.58 / $776.25 / $1,071.52
| Professional | | $426.58 | $776.25 | $1,071.52 |