- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.91 / $128.91 / $221.32
| Professional | | $128.91 | $128.91 | $221.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $235.00 / $343.00 / $578.00
| Professional | | $235.00 | $343.00 | $578.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.07 / $267.58 / $475.17
| Professional | | $172.07 | $267.58 | $475.17 |
- 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
- $297.55 / $417.23 / $827.66
| Professional | | $297.55 | $417.23 | $827.66 |