- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $466.61 / $466.61 / $627.88
| Professional | | $466.61 | $466.61 | $627.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $838.00 / $1,109.00 / $1,618.00
| Professional | | $838.00 | $1,109.00 | $1,618.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $630.48 / $881.16 / $1,510.54
| Professional | | $630.48 | $881.16 | $1,510.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $5,188.00 / $18,767.00
| Facility | | $5,188.00 | $5,188.00 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $701.08 / $1,530.51 / $2,482.92
| Professional | | $701.08 | $1,530.51 | $2,482.92 |