- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.81 / $402.81 / $402.81
| Professional | | $402.81 | $402.81 | $402.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $917.00 / $1,034.00 / $1,241.00
| Professional | | $917.00 | $1,034.00 | $1,241.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $586.14 / $612.79 / $975.05
| Professional | | $586.14 | $612.79 | $975.05 |
- 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
- $524.38 / $1,094.77 / $1,694.87
| Professional | | $524.38 | $1,094.77 | $1,694.87 |