- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,129.22 / $1,359.61 / $2,211.39
| Professional | | $1,129.22 | $1,359.61 | $2,211.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $416.00 / $416.00 / $459.00
| Professional | | $416.00 | $416.00 | $459.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $297.30 / $365.30 / $729.70
| Professional | | $297.30 | $365.30 | $729.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $884.72 / $8,444.70 / $26,542.00
| Facility | | $884.72 | $8,444.70 | $26,542.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,218.00 / $3,304.20 / $3,304.20
| Professional | | $3,218.00 | $3,304.20 | $3,304.20 |