- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.71 / $148.71 / $148.71
| Professional | | $148.71 | $148.71 | $148.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $293.00 / $352.00 / $439.00
| Professional | | $293.00 | $352.00 | $439.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.76 / $251.59 / $345.04
| Professional | | $200.76 | $251.59 | $345.04 |
- 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
- $233.75 / $462.30 / $582.14
| Professional | | $233.75 | $462.30 | $582.14 |