- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $354.81 / $1,000.00
| Professional | | $281.84 | $354.81 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $954.99 / $1,288.25 / $1,513.56
| Facility | | $954.99 | $1,288.25 | $1,513.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $346.74 / $691.83
| Professional | | $257.04 | $346.74 | $691.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $436.52 / $436.52
| Facility | | $436.52 | $436.52 | $436.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $316.23 / $316.23 / $436.52
| Professional | | $316.23 | $316.23 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $398.11 / $457.09 / $812.83
| Facility | | $398.11 | $457.09 | $812.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.12 / $380.19 / $549.54
| Professional | | $295.12 | $380.19 | $549.54 |