- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $366.67 / $366.67 / $366.67
| Professional | | $366.67 | $366.67 | $366.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $674.00 / $809.00 / $1,214.00
| Professional | | $674.00 | $809.00 | $1,214.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $404.53 / $609.58 / $721.82
| Professional | | $404.53 | $609.58 | $721.82 |
- 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
- $458.15 / $765.25 / $1,226.28
| Professional | | $458.15 | $765.25 | $1,226.28 |