- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.77 / $286.77 / $286.77
| Professional | | $286.77 | $286.77 | $286.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $560.00 / $672.00 / $840.00
| Professional | | $560.00 | $672.00 | $840.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $395.36 / $479.51 / $680.76
| Professional | | $395.36 | $479.51 | $680.76 |
- 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
- $466.40 / $742.85 / $1,147.08
| Professional | | $466.40 | $742.85 | $1,147.08 |