- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $373.22 / $373.22 / $373.22
| Professional | | $373.22 | $373.22 | $373.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $852.00 / $961.00 / $1,153.00
| Professional | | $852.00 | $961.00 | $1,153.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $520.16 / $529.30 / $890.79
| Professional | | $520.16 | $529.30 | $890.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $584.10 / $1,168.20 / $1,527.26
| Professional | | $584.10 | $1,168.20 | $1,527.26 |