- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.86 / $197.86 / $1,171.98
| Professional | | $133.86 | $197.86 | $1,171.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $344.00 / $533.00 / $3,053.00
| Professional | | $344.00 | $533.00 | $3,053.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.68 / $576.58 / $1,928.46
| Professional | | $187.68 | $576.58 | $1,928.46 |
- 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
- $854.08 / $1,548.02 / $3,044.58
| Professional | | $854.08 | $1,548.02 | $3,044.58 |