- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.90 / $146.10 / $196.40
| Professional | | $145.90 | $146.10 | $196.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $226.00 / $271.00 / $422.00
| Professional | | $226.00 | $271.00 | $422.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.14 / $265.88 / $448.89
| Professional | | $196.14 | $265.88 | $448.89 |
- 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
- $281.60 / $477.19 / $762.97
| Professional | | $281.60 | $477.19 | $762.97 |