- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.24 / $647.54 / $1,573.62
| Professional | | $247.24 | $647.54 | $1,573.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.00 / $647.00 / $2,649.00
| Professional | | $478.00 | $647.00 | $2,649.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $327.52 / $764.75 / $2,573.81
| Professional | | $327.52 | $764.75 | $2,573.81 |
- 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
- $1,363.31 / $2,139.73 / $3,793.91
| Professional | | $1,363.31 | $2,139.73 | $3,793.91 |