- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.08 / $259.08 / $259.08
| Professional | | $259.08 | $259.08 | $259.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.00 / $572.00 / $859.00
| Professional | | $477.00 | $572.00 | $859.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.64 / $429.13 / $573.08
| Professional | | $326.64 | $429.13 | $573.08 |
- 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
- $367.95 / $735.90 / $967.58
| Professional | | $367.95 | $735.90 | $967.58 |