- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.07 / $660.51 / $1,838.70
| Professional | | $101.07 | $660.51 | $1,838.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $260.00 / $403.00 / $2,682.00
| Professional | | $260.00 | $403.00 | $2,682.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.08 / $428.96 / $1,379.54
| Professional | | $148.08 | $428.96 | $1,379.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.04 / $1,122.04 / $2,185.91
| Professional | | $707.04 | $1,122.04 | $2,185.91 |