- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $323.59 / $588.84
| Professional | | $281.84 | $323.59 | $588.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.78 / $489.78 / $489.78
| Professional | | $489.78 | $489.78 | $489.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $1,000.00
| Facility | | $371.54 | $371.54 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.42 / $275.42 / $676.08
| Professional | | $275.42 | $275.42 | $676.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $190.55 / $323.59 / $758.58
| Facility | | $190.55 | $323.59 | $758.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $281.84 / $426.58
| Professional | | $186.21 | $281.84 | $426.58 |