- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.00 / $2,831.00 / $2,831.00
| Professional | | $277.00 | $2,831.00 | $2,831.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.00 / $508.00 / $741.00
| Professional | | $371.00 | $508.00 | $741.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.40 / $384.72 / $664.17
| Professional | | $234.40 | $384.72 | $664.17 |
- 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
- $402.05 / $703.01 / $1,155.00
| Professional | | $402.05 | $703.01 | $1,155.00 |