- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.07 / $615.07 / $739.26
| Professional | | $615.07 | $615.07 | $739.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,059.00 / $1,412.00 / $1,702.00
| Professional | | $1,059.00 | $1,412.00 | $1,702.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $654.49 / $913.40 / $1,229.58
| Professional | | $654.49 | $913.40 | $1,229.58 |
- 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
- $746.33 / $1,258.43 / $1,901.89
| Professional | | $746.33 | $1,258.43 | $1,901.89 |