- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $138.04 / $269.15
| Professional | | $79.43 | $138.04 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $416.87 / $1,023.29
| Professional | | $223.87 | $416.87 | $1,023.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.33 / $186.21 / $436.52
| Professional | | $93.33 | $186.21 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,288.25 / $5,370.32
| Facility | | $1,000.00 | $1,288.25 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.65 / $181.97 / $426.58
| Professional | | $109.65 | $181.97 | $426.58 |