- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $403.66 / $403.66 / $403.66
| Professional | | $403.66 | $403.66 | $403.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $855.00 / $1,026.00 / $1,496.00
| Professional | | $855.00 | $1,026.00 | $1,496.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.29 / $798.30 / $990.15
| Professional | | $530.29 | $798.30 | $990.15 |
- 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
- $607.76 / $1,047.45 / $1,701.46
| Professional | | $607.76 | $1,047.45 | $1,701.46 |