- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $487.69 / $487.69 / $487.69
| Professional | | $487.69 | $487.69 | $487.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $957.00 / $1,148.00 / $1,435.00
| Professional | | $957.00 | $1,148.00 | $1,435.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $657.88 / $821.25 / $1,137.40
| Professional | | $657.88 | $821.25 | $1,137.40 |
- 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
- $760.65 / $1,222.58 / $1,898.16
| Professional | | $760.65 | $1,222.58 | $1,898.16 |