- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $473.14 / $473.14 / $665.90
| Professional | | $473.14 | $473.14 | $665.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $768.00 / $1,537.00 / $2,124.00
| Professional | | $768.00 | $1,537.00 | $2,124.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $611.73 / $968.06 / $1,366.85
| Professional | | $611.73 | $968.06 | $1,366.85 |
- 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
- $933.35 / $1,636.75 / $2,835.37
| Professional | | $933.35 | $1,636.75 | $2,835.37 |