- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $339.05 / $506.05 / $4,117.30
| Professional | | $339.05 | $506.05 | $4,117.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $507.00 / $756.00 / $1,049.00
| Professional | | $507.00 | $756.00 | $1,049.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.81 / $624.89 / $905.53
| Professional | | $436.81 | $624.89 | $905.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.00 / $293.00 / $3,239.00
| Facility | | $293.00 | $293.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $580.78 / $861.61 / $1,596.11
| Professional | | $580.78 | $861.61 | $1,596.11 |