- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $566.73 / $566.73 / $566.73
| Professional | | $566.73 | $566.73 | $566.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $896.00 / $1,075.00 / $2,152.00
| Professional | | $896.00 | $1,075.00 | $2,152.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $675.13 / $937.15 / $1,259.77
| Professional | | $675.13 | $937.15 | $1,259.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $5,188.00 / $18,767.00
| Facility | | $5,188.00 | $5,188.00 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $774.40 / $1,334.64 / $2,171.41
| Professional | | $774.40 | $1,334.64 | $2,171.41 |