- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $366.17 / $366.17 / $474.15
| Professional | | $366.17 | $366.17 | $474.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.00 / $1,741.00 / $2,222.00
| Professional | | $1,077.00 | $1,741.00 | $2,222.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $464.97 / $604.46 / $883.44
| Professional | | $464.97 | $604.46 | $883.44 |
- 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
- $481.27 / $912.45 / $1,476.81
| Professional | | $481.27 | $912.45 | $1,476.81 |