- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $347.36 / $347.36 / $347.36
| Professional | | $347.36 | $347.36 | $347.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $640.00 / $768.00 / $1,152.00
| Professional | | $640.00 | $768.00 | $1,152.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.05 / $577.34 / $753.56
| Professional | | $411.05 | $577.34 | $753.56 |
- 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
- $463.65 / $802.60 / $1,232.88
| Professional | | $463.65 | $802.60 | $1,232.88 |