- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.57 / $274.33 / $360.93
| Professional | | $253.57 | $274.33 | $360.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.00 / $848.00 / $1,313.00
| Professional | | $707.00 | $848.00 | $1,313.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $290.63 / $454.97 / $723.40
| Professional | | $290.63 | $454.97 | $723.40 |
- 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
- $319.18 / $541.14 / $1,231.56
| Professional | | $319.18 | $541.14 | $1,231.56 |