- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $466.96 / $466.96 / $466.96
| Professional | | $466.96 | $466.96 | $466.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $863.00 / $1,036.00 / $1,553.00
| Professional | | $863.00 | $1,036.00 | $1,553.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $571.04 / $776.64 / $1,001.34
| Professional | | $571.04 | $776.64 | $1,001.34 |
- 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
- $642.94 / $1,069.05 / $1,712.05
| Professional | | $642.94 | $1,069.05 | $1,712.05 |