- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.16 / $140.16 / $201.76
| Professional | | $140.16 | $140.16 | $201.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.00 / $363.00 / $530.00
| Professional | | $256.00 | $363.00 | $530.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.64 / $257.87 / $427.37
| Professional | | $187.64 | $257.87 | $427.37 |
- 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
- $295.91 / $478.07 / $733.92
| Professional | | $295.91 | $478.07 | $733.92 |