- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.21 / $1,448.30 / $2,237.34
| Professional | | $149.21 | $1,448.30 | $2,237.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $198.37 / $702.00 / $877.50
| Professional | | $198.37 | $702.00 | $877.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,448.30 / $1,485.84 / $4,313.93
| Facility | | $1,448.30 | $1,485.84 | $4,313.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.00 / $1.00 / $1.00
| Facility | | $1.00 | $1.00 | $1.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,468.75 / $3,125.00 / $3,125.00
| Professional | | $2,468.75 | $3,125.00 | $3,125.00 |