- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $743.71 / $744.01 / $940.48
| Professional | | $743.71 | $744.01 | $940.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,423.00 / $1,708.00 / $2,584.00
| Professional | | $1,423.00 | $1,708.00 | $2,584.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,003.26 / $1,488.02 / $2,059.67
| Professional | | $1,003.26 | $1,488.02 | $2,059.67 |
- 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
- $798.39 / $1,473.17 / $2,430.98
| Professional | | $798.39 | $1,473.17 | $2,430.98 |