- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $468.45 / $468.45 / $468.45
| Professional | | $468.45 | $468.45 | $468.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $913.00 / $1,096.00 / $1,369.00
| Professional | | $913.00 | $1,096.00 | $1,369.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $644.49 / $781.09 / $1,111.15
| Professional | | $644.49 | $781.09 | $1,111.15 |
- 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
- $756.25 / $1,201.83 / $1,854.61
| Professional | | $756.25 | $1,201.83 | $1,854.61 |