- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.74 / $149.74 / $183.31
| Professional | | $149.74 | $149.74 | $183.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.00 / $334.00 / $501.00
| Professional | | $277.00 | $334.00 | $501.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.34 / $250.45 / $314.36
| Professional | | $162.34 | $250.45 | $314.36 |
- 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
- $199.10 / $353.83 / $531.95
| Professional | | $199.10 | $353.83 | $531.95 |