- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.44 / $379.05 / $1,718.54
| Professional | | $198.44 | $379.05 | $1,718.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.00 / $785.00 / $3,883.00
| Professional | | $508.00 | $785.00 | $3,883.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.39 / $851.04 / $2,847.64
| Professional | | $300.39 | $851.04 | $2,847.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,432.62 / $2,375.87 / $5,812.30
| Professional | | $1,432.62 | $2,375.87 | $5,812.30 |