- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.65 / $317.13 / $487.87
| Professional | | $206.65 | $317.13 | $487.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $892.00 / $1,070.00 / $1,656.00
| Professional | | $892.00 | $1,070.00 | $1,656.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.93 / $438.30 / $714.67
| Professional | | $261.93 | $438.30 | $714.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $5,484.78 / $10,877.00
| Facility | | $2,607.00 | $5,484.78 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.95 / $577.79 / $1,172.14
| Professional | | $288.95 | $577.79 | $1,172.14 |