- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.18 / $607.60 / $2,571.65
| Professional | | $257.18 | $607.60 | $2,571.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $661.00 / $1,023.00 / $2,668.00
| Professional | | $661.00 | $1,023.00 | $2,668.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $356.11 / $667.21 / $1,547.86
| Professional | | $356.11 | $667.21 | $1,547.86 |
- 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
- $737.07 / $1,320.88 / $2,167.53
| Professional | | $737.07 | $1,320.88 | $2,167.53 |