- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.36 / $138.36 / $138.36
| Professional | | $138.36 | $138.36 | $138.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.00 / $355.00 / $426.00
| Professional | | $315.00 | $355.00 | $426.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.65 / $208.06 / $318.02
| Professional | | $184.65 | $208.06 | $318.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,934.00 / $6,934.00 / $26,502.00
| Facility | | $6,934.00 | $6,934.00 | $26,502.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.90 / $453.10 / $612.46
| Professional | | $181.90 | $453.10 | $612.46 |