- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.50 / $149.40 / $715.83
| Professional | | $148.50 | $149.40 | $715.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $265.00 / $386.00 / $1,733.00
| Professional | | $265.00 | $386.00 | $1,733.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.82 / $358.81 / $1,323.56
| Professional | | $210.82 | $358.81 | $1,323.56 |
- 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
- $1,088.09 / $1,900.11 / $3,760.68
| Professional | | $1,088.09 | $1,900.11 | $3,760.68 |