- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.04 / $239.88 / $389.05
| Professional | | $138.04 | $239.88 | $389.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $676.08 / $1,047.13
| Professional | | $380.19 | $676.08 | $1,047.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.88 / $302.00 / $575.44
| Professional | | $154.88 | $302.00 | $575.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,288.25 / $5,370.32
| Facility | | $1,258.93 | $1,288.25 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $316.23 / $676.08
| Professional | | $173.78 | $316.23 | $676.08 |