- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.66 / $413.69 / $877.87
| Professional | | $154.66 | $413.69 | $877.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $313.00 / $424.00 / $1,516.00
| Professional | | $313.00 | $424.00 | $1,516.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $210.65 / $502.22 / $1,288.72
| Professional | | $210.65 | $502.22 | $1,288.72 |
- 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
- $774.20 / $1,173.65 / $2,136.19
| Professional | | $774.20 | $1,173.65 | $2,136.19 |