- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $514.73 / $533.13 / $645.23
| Professional | | $514.73 | $533.13 | $645.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,012.00 / $1,214.00 / $1,837.00
| Professional | | $1,012.00 | $1,214.00 | $1,837.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $727.83 / $1,028.88 / $1,430.27
| Professional | | $727.83 | $1,028.88 | $1,430.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,934.00 / $6,934.00 / $26,502.00
| Facility | | $6,934.00 | $6,934.00 | $26,502.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $761.46 / $1,082.40 / $2,191.81
| Professional | | $761.46 | $1,082.40 | $2,191.81 |