- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $475.53 / $475.53 / $475.53
| Professional | | $475.53 | $475.53 | $475.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $940.00 / $1,128.00 / $1,817.00
| Professional | | $940.00 | $1,128.00 | $1,817.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $776.88 / $838.34 / $1,138.11
| Professional | | $776.88 | $838.34 | $1,138.11 |
- 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
- $681.65 / $1,516.86 / $2,405.06
| Professional | | $681.65 | $1,516.86 | $2,405.06 |