- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.76 / $197.76 / $197.76
| Professional | | $197.76 | $197.76 | $197.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $386.00 / $386.00 / $463.00
| Professional | | $386.00 | $386.00 | $463.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.31 / $313.58 / $458.05
| Professional | | $268.31 | $313.58 | $458.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $5,188.00 / $18,767.00
| Facility | | $5,188.00 | $5,188.00 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $299.75 / $452.35 / $719.38
| Professional | | $299.75 | $452.35 | $719.38 |