- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $376.63 / $376.63 / $538.71
| Professional | | $376.63 | $376.63 | $538.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $951.00 / $1,471.00 / $2,102.00
| Professional | | $951.00 | $1,471.00 | $2,102.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $409.86 / $609.71 / $896.71
| Professional | | $409.86 | $609.71 | $896.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.00 / $293.00 / $3,239.00
| Facility | | $293.00 | $293.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $547.79 / $872.40 / $1,369.51
| Professional | | $547.79 | $872.40 | $1,369.51 |