- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $288.40 / $562.34
| Professional | | $144.54 | $288.40 | $562.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $933.25 / $1,584.89
| Professional | | $588.84 | $933.25 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $223.87 / $331.13 / $616.60
| Professional | | $223.87 | $331.13 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,995.26 / $3,235.94
| Facility | | $794.33 | $1,995.26 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.03 / $512.86 / $1,000.00
| Professional | | $263.03 | $512.86 | $1,000.00 |