- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.83 / $184.83 / $366.51
| Professional | | $184.83 | $184.83 | $366.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.00 / $510.00 / $983.00
| Professional | | $340.00 | $510.00 | $983.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $253.05 / $419.76 / $733.33
| Professional | | $253.05 | $419.76 | $733.33 |
- 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
- $482.36 / $804.27 / $1,276.43
| Professional | | $482.36 | $804.27 | $1,276.43 |