- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $446.42 / $446.42 / $446.42
| Professional | | $446.42 | $446.42 | $446.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $824.00 / $989.00 / $1,484.00
| Professional | | $824.00 | $989.00 | $1,484.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $552.64 / $741.74 / $951.23
| Professional | | $552.64 | $741.74 | $951.23 |
- 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
- $636.35 / $1,074.01 / $1,742.41
| Professional | | $636.35 | $1,074.01 | $1,742.41 |