- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $736.73 / $755.93 / $940.65
| Professional | | $736.73 | $755.93 | $940.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,431.00 / $1,717.00 / $2,598.00
| Professional | | $1,431.00 | $1,717.00 | $2,598.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.12 / $1,462.69 / $2,045.32
| Professional | | $975.12 | $1,462.69 | $2,045.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.00 / $293.00 / $3,239.00
| Facility | | $293.00 | $293.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $972.51 / $1,436.25 / $2,668.89
| Professional | | $972.51 | $1,436.25 | $2,668.89 |