- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $454.11 / $454.11 / $454.11
| Professional | | $454.11 | $454.11 | $454.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $823.00 / $988.00 / $1,441.00
| Professional | | $823.00 | $988.00 | $1,441.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $610.12 / $763.32 / $1,057.21
| Professional | | $610.12 | $763.32 | $1,057.21 |
- 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
- $709.50 / $1,012.59 / $1,764.83
| Professional | | $709.50 | $1,012.59 | $1,764.83 |