- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $506.17 / $506.17 / $506.17
| Professional | | $506.17 | $506.17 | $506.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $896.00 / $1,075.00 / $1,570.00
| Professional | | $896.00 | $1,075.00 | $1,570.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $557.39 / $836.63 / $1,036.30
| Professional | | $557.39 | $836.63 | $1,036.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $640.20 / $1,436.73 / $1,787.28
| Professional | | $640.20 | $1,436.73 | $1,787.28 |