- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.32 / $5,890.50 / $5,890.50
| Professional | | $257.32 | $5,890.50 | $5,890.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.00 / $260.00 / $380.00
| Professional | | $217.00 | $260.00 | $380.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.59 / $202.70 / $282.54
| Professional | | $151.59 | $202.70 | $282.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.80 / $261.48 / $488.40
| Professional | | $173.80 | $261.48 | $488.40 |