- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $493.88 / $493.88 / $493.88
| Professional | | $493.88 | $493.88 | $493.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $872.00 / $1,046.00 / $1,528.00
| Professional | | $872.00 | $1,046.00 | $1,528.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.89 / $815.05 / $1,005.45
| Professional | | $537.89 | $815.05 | $1,005.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $10,877.00 / $11,831.32
| Facility | | $2,607.00 | $10,877.00 | $11,831.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $618.20 / $1,066.56 / $1,733.15
| Professional | | $618.20 | $1,066.56 | $1,733.15 |