- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $214.15 / $304.55 / $346.03
| Professional | | $214.15 | $304.55 | $346.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $567.00 / $874.00 / $1,352.00
| Professional | | $567.00 | $874.00 | $1,352.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.69 / $446.33 / $775.96
| Professional | | $261.69 | $446.33 | $775.96 |
- 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
- $338.96 / $602.11 / $1,309.43
| Professional | | $338.96 | $602.11 | $1,309.43 |