- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $472.45 / $472.45 / $472.45
| Professional | | $472.45 | $472.45 | $472.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.00 / $1,112.00 / $1,391.00
| Professional | | $927.00 | $1,112.00 | $1,391.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $631.50 / $796.68 / $1,096.82
| Professional | | $631.50 | $796.68 | $1,096.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $734.80 / $1,182.74 / $1,837.43
| Professional | | $734.80 | $1,182.74 | $1,837.43 |