- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $279.77 / $809.18 / $1,630.20
| Professional | | $279.77 | $809.18 | $1,630.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $613.00 / $830.00 / $2,730.00
| Professional | | $613.00 | $830.00 | $2,730.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $376.50 / $981.08 / $2,662.23
| Professional | | $376.50 | $981.08 | $2,662.23 |
- 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
- $1,524.95 / $2,268.60 / $4,174.47
| Professional | | $1,524.95 | $2,268.60 | $4,174.47 |