- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $727.51 / $733.22 / $921.83
| Professional | | $727.51 | $733.22 | $921.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,394.00 / $1,673.00 / $2,531.00
| Professional | | $1,394.00 | $1,673.00 | $2,531.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $960.38 / $1,440.57 / $2,021.96
| Professional | | $960.38 | $1,440.57 | $2,021.96 |
- 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
- $913.77 / $1,429.28 / $2,507.69
| Professional | | $913.77 | $1,429.28 | $2,507.69 |