- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.76 / $234.76 / $377.34
| Professional | | $234.76 | $234.76 | $377.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $687.00 / $1,110.00 / $1,763.00
| Professional | | $687.00 | $1,110.00 | $1,763.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.42 / $468.30 / $702.68
| Professional | | $320.42 | $468.30 | $702.68 |
- 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
- $382.94 / $727.88 / $1,194.69
| Professional | | $382.94 | $727.88 | $1,194.69 |