- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $102.11 / $964.98 / $964.98
| Professional | | $102.11 | $964.98 | $964.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.00 / $187.00 / $224.00
| Professional | | $157.00 | $187.00 | $224.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.37 / $169.15 / $243.14
| Professional | | $138.37 | $169.15 | $243.14 |
- 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
- $154.55 / $235.71 / $411.85
| Professional | | $154.55 | $235.71 | $411.85 |