- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.06 / $189.06 / $231.97
| Professional | | $189.06 | $189.06 | $231.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.00 / $453.00 / $566.00
| Professional | | $371.00 | $453.00 | $566.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.87 / $317.91 / $506.14
| Professional | | $251.87 | $317.91 | $506.14 |
- 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
- $343.20 / $554.42 / $857.98
| Professional | | $343.20 | $554.42 | $857.98 |