- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $977.28 / $977.28 / $977.28
| Professional | | $977.28 | $977.28 | $977.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,234.00 / $2,519.00 / $3,023.00
| Professional | | $2,234.00 | $2,519.00 | $3,023.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,407.91 / $1,475.21 / $2,503.96
| Professional | | $1,407.91 | $1,475.21 | $2,503.96 |
- 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
- $1,269.99 / $3,212.00 / $4,118.39
| Professional | | $1,269.99 | $3,212.00 | $4,118.39 |