- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $438.21 / $438.21 / $438.21
| Professional | | $438.21 | $438.21 | $438.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $998.00 / $1,125.00 / $1,350.00
| Professional | | $998.00 | $1,125.00 | $1,350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $638.07 / $661.52 / $1,061.36
| Professional | | $638.07 | $661.52 | $1,061.36 |
- 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
- $557.54 / $1,449.93 / $1,842.70
| Professional | | $557.54 | $1,449.93 | $1,842.70 |