- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.08 / $246.08 / $565.15
| Professional | | $246.08 | $246.08 | $565.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $479.00 / $599.00 / $1,321.00
| Professional | | $479.00 | $599.00 | $1,321.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.10 / $583.50 / $1,106.75
| Professional | | $338.10 | $583.50 | $1,106.75 |
- 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
- $830.50 / $1,167.77 / $1,964.16
| Professional | | $830.50 | $1,167.77 | $1,964.16 |