- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $675.27 / $675.57 / $852.38
| Professional | | $675.27 | $675.57 | $852.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,294.00 / $1,553.00 / $2,348.00
| Professional | | $1,294.00 | $1,553.00 | $2,348.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $914.81 / $1,351.13 / $1,869.72
| Professional | | $914.81 | $1,351.13 | $1,869.72 |
- 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
- $737.07 / $1,340.11 / $2,256.78
| Professional | | $737.07 | $1,340.11 | $2,256.78 |