- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.02 / $300.02 / $300.02
| Professional | | $300.02 | $300.02 | $300.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $476.00 / $723.00 / $1,118.00
| Professional | | $476.00 | $723.00 | $1,118.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.10 / $395.24 / $678.26
| Professional | | $245.10 | $395.24 | $678.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $393.80 / $886.71 / $1,123.32
| Professional | | $393.80 | $886.71 | $1,123.32 |