- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.61 / $409.26 / $449.90
| Professional | | $291.61 | $409.26 | $449.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $753.00 / $1,127.00 / $1,744.00
| Professional | | $753.00 | $1,127.00 | $1,744.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $345.02 / $601.74 / $1,040.14
| Professional | | $345.02 | $601.74 | $1,040.14 |
- 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
- $432.40 / $820.29 / $1,422.20
| Professional | | $432.40 | $820.29 | $1,422.20 |