- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $712.78 / $713.76 / $902.60
| Professional | | $712.78 | $713.76 | $902.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,365.00 / $1,638.00 / $2,478.00
| Professional | | $1,365.00 | $1,638.00 | $2,478.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $959.84 / $1,427.52 / $1,976.46
| Professional | | $959.84 | $1,427.52 | $1,976.46 |
- 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
- $992.24 / $1,410.46 / $2,473.89
| Professional | | $992.24 | $1,410.46 | $2,473.89 |