- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $441.04 / $441.04 / $441.04
| Professional | | $441.04 | $441.04 | $441.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $815.00 / $978.00 / $1,468.00
| Professional | | $815.00 | $978.00 | $1,468.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $537.13 / $733.75 / $933.14
| Professional | | $537.13 | $733.75 | $933.14 |
- 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
- $606.10 / $1,006.78 / $1,610.40
| Professional | | $606.10 | $1,006.78 | $1,610.40 |