- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.17 / $275.17 / $275.17
| Professional | | $275.17 | $275.17 | $275.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $536.00 / $643.00 / $804.00
| Professional | | $536.00 | $643.00 | $804.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $378.78 / $459.35 / $654.88
| Professional | | $378.78 | $459.35 | $654.88 |
- 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
- $342.01 / $623.84 / $1,092.95
| Professional | | $342.01 | $623.84 | $1,092.95 |