- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.46 / $211.46 / $2,529.39
| Professional | | $211.46 | $211.46 | $2,529.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $482.00 / $578.00 / $5,679.00
| Professional | | $482.00 | $578.00 | $5,679.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.80 / $468.51 / $5,374.85
| Professional | | $261.80 | $468.51 | $5,374.85 |
- 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
- $2,965.05 / $5,704.75 / $10,893.95
| Professional | | $2,965.05 | $5,704.75 | $10,893.95 |