- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $550.53 / $550.53 / $550.53
| Professional | | $550.53 | $550.53 | $550.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $982.00 / $1,178.00 / $1,720.00
| Professional | | $982.00 | $1,178.00 | $1,720.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $672.19 / $914.65 / $1,240.56
| Professional | | $672.19 | $914.65 | $1,240.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $6,486.14 / $10,877.00
| Facility | | $2,607.00 | $6,486.14 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $768.90 / $1,318.05 / $2,139.71
| Professional | | $768.90 | $1,318.05 | $2,139.71 |