- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $501.02 / $501.02 / $501.02
| Professional | | $501.02 | $501.02 | $501.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $909.00 / $1,091.00 / $1,592.00
| Professional | | $909.00 | $1,091.00 | $1,592.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $673.99 / $843.40 / $1,165.82
| Professional | | $673.99 | $843.40 | $1,165.82 |
- 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
- $789.26 / $1,264.08 / $1,952.29
| Professional | | $789.26 | $1,264.08 | $1,952.29 |