- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $388.17 / $388.17 / $388.17
| Professional | | $388.17 | $388.17 | $388.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $756.00 / $907.00 / $1,135.00
| Professional | | $756.00 | $907.00 | $1,135.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $533.22 / $647.54 / $919.86
| Professional | | $533.22 | $647.54 | $919.86 |
- 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
- $678.59 / $1,224.51 / $1,973.39
| Professional | | $678.59 | $1,224.51 | $1,973.39 |