- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $381.55 / $381.55 / $1,780.68
| Professional | | $381.55 | $381.55 | $1,780.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $752.00 / $940.00 / $4,068.00
| Professional | | $752.00 | $940.00 | $4,068.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $513.20 / $882.15 / $4,205.80
| Professional | | $513.20 | $882.15 | $4,205.80 |
- 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
- $2,862.74 / $4,320.14 / $6,870.61
| Professional | | $2,862.74 | $4,320.14 | $6,870.61 |