- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $372.82 / $372.82 / $1,027.43
| Professional | | $372.82 | $372.82 | $1,027.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $668.00 / $835.00 / $2,164.00
| Professional | | $668.00 | $835.00 | $2,164.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $473.48 / $815.33 / $1,852.15
| Professional | | $473.48 | $815.33 | $1,852.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,392.68 / $2,247.64 / $3,340.98
| Professional | | $1,392.68 | $2,247.64 | $3,340.98 |