- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,395.69 / $1,680.45 / $2,733.24
| Professional | | $1,395.69 | $1,680.45 | $2,733.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $528.00 / $528.00 / $575.00
| Professional | | $528.00 | $528.00 | $575.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $394.60 / $471.70 / $904.40
| Professional | | $394.60 | $471.70 | $904.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $977.98 / $8,444.70 / $26,542.00
| Facility | | $977.98 | $8,444.70 | $26,542.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,886.14 / $2,886.14 / $2,886.14
| Professional | | $2,886.14 | $2,886.14 | $2,886.14 |