- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $462.23 / $462.23 / $462.23
| Professional | | $462.23 | $462.23 | $462.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $942.00 / $1,130.00 / $1,820.00
| Professional | | $942.00 | $1,130.00 | $1,820.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $505.33 / $757.98 / $912.47
| Professional | | $505.33 | $757.98 | $912.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $598.40 / $952.84 / $1,473.12
| Professional | | $598.40 | $952.84 | $1,473.12 |