- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $342.92 / $342.92 / $342.92
| Professional | | $342.92 | $342.92 | $342.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $631.00 / $757.00 / $1,135.00
| Professional | | $631.00 | $757.00 | $1,135.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $403.70 / $569.04 / $708.01
| Professional | | $403.70 | $569.04 | $708.01 |
- 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
- $454.85 / $909.70 / $1,211.78
| Professional | | $454.85 | $909.70 | $1,211.78 |