- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.05 / $411.05 / $411.05
| Professional | | $411.05 | $411.05 | $411.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $937.00 / $1,057.00 / $1,268.00
| Professional | | $937.00 | $1,057.00 | $1,268.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $545.24 / $552.44 / $1,054.19
| Professional | | $545.24 | $552.44 | $1,054.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $496.44 / $1,230.91 / $1,750.33
| Professional | | $496.44 | $1,230.91 | $1,750.33 |