- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $437.24 / $437.24 / $437.24
| Professional | | $437.24 | $437.24 | $437.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $808.00 / $970.00 / $1,453.00
| Professional | | $808.00 | $970.00 | $1,453.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $534.82 / $726.73 / $932.50
| Professional | | $534.82 | $726.73 | $932.50 |
- 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
- $602.25 / $993.52 / $1,586.63
| Professional | | $602.25 | $993.52 | $1,586.63 |