- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.39 / $263.39 / $263.39
| Professional | | $263.39 | $263.39 | $263.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $511.00 / $613.00 / $767.00
| Professional | | $511.00 | $613.00 | $767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $362.88 / $437.59 / $626.58
| Professional | | $362.88 | $437.59 | $626.58 |
- 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
- $426.79 / $677.29 / $1,044.13
| Professional | | $426.79 | $677.29 | $1,044.13 |