- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $459.59 / $459.59 / $459.59
| Professional | | $459.59 | $459.59 | $459.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $901.00 / $1,081.00 / $1,351.00
| Professional | | $901.00 | $1,081.00 | $1,351.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $618.12 / $773.63 / $1,070.94
| Professional | | $618.12 | $773.63 | $1,070.94 |
- 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
- $720.49 / $1,155.35 / $1,788.60
| Professional | | $720.49 | $1,155.35 | $1,788.60 |