- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $450.64 / $450.64 / $450.64
| Professional | | $450.64 | $450.64 | $450.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.00 / $974.00 / $1,423.00
| Professional | | $812.00 | $974.00 | $1,423.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $348.47 / $493.95 / $750.15
| Professional | | $348.47 | $493.95 | $750.15 |
- 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
- $390.50 / $923.01 / $1,398.84
| Professional | | $390.50 | $923.01 | $1,398.84 |