- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.12 / $237.12 / $237.12
| Professional | | $237.12 | $237.12 | $237.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $642.27 / $785.00 / $1,380.21
| Professional | | $642.27 | $785.00 | $1,380.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.78 / $400.00 / $1,725.00
| Facility | | $239.78 | $400.00 | $1,725.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.55 / $410.70 / $2,635.54
| Professional | | $167.55 | $410.70 | $2,635.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.55 / $321.80 / $455.72
| Professional | | $167.55 | $321.80 | $455.72 |