- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $363.08 / $602.56
| Professional | | $194.98 | $363.08 | $602.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.03 / $1,000.00 / $1,621.81
| Professional | | $537.03 | $1,000.00 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.78 / $457.09 / $891.25
| Professional | | $218.78 | $457.09 | $891.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.25 / $1,288.25 / $5,370.32
| Facility | | $776.25 | $1,288.25 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.04 / $489.78 / $1,122.02
| Professional | | $257.04 | $489.78 | $1,122.02 |