- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $840.04 / $1,011.43 / $1,645.09
| Professional | | $840.04 | $1,011.43 | $1,645.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $370.00 / $370.00 / $370.00
| Professional | | $370.00 | $370.00 | $370.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $332.50 / $385.80 / $505.00
| Professional | | $332.50 | $385.80 | $505.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $652.74 / $9,561.75 / $26,542.00
| Facility | | $652.74 | $9,561.75 | $26,542.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,301.00 / $3,301.00 / $3,301.00
| Professional | | $3,301.00 | $3,301.00 | $3,301.00 |