- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.25 / $271.97 / $1,074.01
| Professional | | $195.25 | $271.97 | $1,074.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $512.00 / $792.00 / $2,508.00
| Professional | | $512.00 | $792.00 | $2,508.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.25 / $479.09 / $1,445.97
| Professional | | $289.25 | $479.09 | $1,445.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $3,793.98 / $5,606.00
| Facility | | $1,275.00 | $3,793.98 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $427.90 / $1,011.39 / $2,023.53
| Professional | | $427.90 | $1,011.39 | $2,023.53 |