- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $487.34 / $487.34 / $487.34
| Professional | | $487.34 | $487.34 | $487.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $956.00 / $1,147.00 / $1,434.00
| Professional | | $956.00 | $1,147.00 | $1,434.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $656.95 / $820.67 / $1,135.78
| Professional | | $656.95 | $820.67 | $1,135.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $765.60 / $1,228.40 / $1,902.11
| Professional | | $765.60 | $1,228.40 | $1,902.11 |