- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.18 / $185.18 / $213.56
| Professional | | $185.18 | $185.18 | $213.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $363.00 / $418.00 / $523.00
| Professional | | $363.00 | $418.00 | $523.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.52 / $312.08 / $479.49
| Professional | | $248.52 | $312.08 | $479.49 |
- 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
- $325.05 / $535.35 / $826.34
| Professional | | $325.05 | $535.35 | $826.34 |