- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.51 / $176.78 / $1,368.45
| Professional | | $117.51 | $176.78 | $1,368.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $303.00 / $469.00 / $4,982.00
| Professional | | $303.00 | $469.00 | $4,982.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.88 / $502.03 / $2,244.11
| Professional | | $162.88 | $502.03 | $2,244.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $788.00 / $788.00 / $3,328.00
| Facility | | $788.00 | $788.00 | $3,328.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,242.20 / $2,105.46 / $3,731.63
| Professional | | $1,242.20 | $2,105.46 | $3,731.63 |