- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.43 / $221.43 / $2,565.30
| Professional | | $221.43 | $221.43 | $2,565.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.00 / $545.00 / $5,803.00
| Professional | | $436.00 | $545.00 | $5,803.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $305.31 / $526.69 / $4,051.60
| Professional | | $305.31 | $526.69 | $4,051.60 |
- 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
- $2,363.35 / $4,637.72 / $6,471.24
| Professional | | $2,363.35 | $4,637.72 | $6,471.24 |