- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $506.09 / $506.09 / $5,885.97
| Professional | | $506.09 | $506.09 | $5,885.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,143.00 / $1,372.00 / $13,752.00
| Professional | | $1,143.00 | $1,372.00 | $13,752.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $689.28 / $1,175.07 / $15,458.05
| Professional | | $689.28 | $1,175.07 | $15,458.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $16,952.00 / $16,952.00 / $34,440.00
| Facility | | $16,952.00 | $16,952.00 | $34,440.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,524.25 / $14,095.49 / $25,258.18
| Professional | | $10,524.25 | $14,095.49 | $25,258.18 |