- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $110.36 / $110.36 / $240.13
| Professional | | $110.36 | $110.36 | $240.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.00 / $301.00 / $605.00
| Professional | | $251.00 | $301.00 | $605.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.31 / $252.85 / $481.19
| Professional | | $144.31 | $252.85 | $481.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $788.00 / $788.00 / $3,328.00
| Facility | | $788.00 | $788.00 | $3,328.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $290.39 / $547.02 / $809.16
| Professional | | $290.39 | $547.02 | $809.16 |