- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.61 / $203.27 / $251.90
| Professional | | $197.61 | $203.27 | $251.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,304.00 / $1,304.00 / $1,304.00
| Facility | | $1,304.00 | $1,304.00 | $1,304.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $384.00 / $461.00 / $697.00
| Professional | | $384.00 | $461.00 | $697.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $254.31 / $381.47 / $565.75
| Professional | | $254.31 | $381.47 | $565.75 |
- 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
- $196.84 / $375.42 / $604.50
| Professional | | $196.84 | $375.42 | $604.50 |