- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $317.10 / $317.10 / $914.06
| Professional | | $317.10 | $317.10 | $914.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $727.00 / $872.00 / $2,175.00
| Professional | | $727.00 | $872.00 | $2,175.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $441.43 / $735.63 / $2,249.67
| Professional | | $441.43 | $735.63 | $2,249.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,934.00 / $6,934.00 / $26,502.00
| Facility | | $6,934.00 | $6,934.00 | $26,502.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,719.60 / $2,959.78 / $4,493.28
| Professional | | $1,719.60 | $2,959.78 | $4,493.28 |