- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $926.08 / $1,115.02 / $1,813.58
| Professional | | $926.08 | $1,115.02 | $1,813.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $406.00 / $406.00 / $406.00
| Professional | | $406.00 | $406.00 | $406.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $369.10 / $435.80 / $557.90
| Professional | | $369.10 | $435.80 | $557.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $712.78 / $9,561.75 / $26,542.00
| Facility | | $712.78 | $9,561.75 | $26,542.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,619.00 / $3,619.00 / $3,619.00
| Professional | | $3,619.00 | $3,619.00 | $3,619.00 |