- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $554.26 / $557.30 / $702.08
| Professional | | $554.26 | $557.30 | $702.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,064.00 / $1,277.00 / $1,931.00
| Professional | | $1,064.00 | $1,277.00 | $1,931.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $736.19 / $1,104.29 / $1,543.23
| Professional | | $736.19 | $1,104.29 | $1,543.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,200.00 / $4,200.00 / $14,634.00
| Facility | | $4,200.00 | $4,200.00 | $14,634.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $584.54 / $1,087.98 / $1,752.41
| Professional | | $584.54 | $1,087.98 | $1,752.41 |