- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.83 / $525.83 / $525.83
| Professional | | $525.83 | $525.83 | $525.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $955.00 / $1,146.00 / $1,672.00
| Professional | | $955.00 | $1,146.00 | $1,672.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $706.51 / $886.19 / $1,277.42
| Professional | | $706.51 | $886.19 | $1,277.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $788.00 / $788.00 / $3,328.00
| Facility | | $788.00 | $788.00 | $3,328.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $795.30 / $1,312.24 / $2,015.62
| Professional | | $795.30 | $1,312.24 | $2,015.62 |