- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $421.83 / $425.83 / $5,163.31
| Professional | | $421.83 | $425.83 | $5,163.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $956.00 / $1,147.00 / $11,772.00
| Professional | | $956.00 | $1,147.00 | $11,772.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.03 / $1,049.91 / $10,845.64
| Professional | | $615.03 | $1,049.91 | $10,845.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,509.00 / $8,509.00 / $27,952.00
| Facility | | $8,509.00 | $8,509.00 | $27,952.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,127.78 / $15,684.14 / $17,075.50
| Professional | | $6,127.78 | $15,684.14 | $17,075.50 |