- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.66 / $134.97 / $644.83
| Professional | | $133.66 | $134.97 | $644.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.00 / $374.00 / $1,492.00
| Professional | | $234.00 | $374.00 | $1,492.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $178.39 / $316.24 / $1,384.42
| Professional | | $178.39 | $316.24 | $1,384.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $788.00 / $788.00 / $3,328.00
| Facility | | $788.00 | $788.00 | $3,328.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $728.31 / $1,051.80 / $2,427.67
| Professional | | $728.31 | $1,051.80 | $2,427.67 |