- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,876.00 / $5,341.85 / $7,588.60
| Professional | | $3,876.00 | $5,341.85 | $7,588.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $865.00 / $1,038.00 / $1,094.00
| Professional | | $865.00 | $1,038.00 | $1,094.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $546.08 / $706.83 / $1,205.99
| Professional | | $546.08 | $706.83 | $1,205.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $572.23 / $1,051.75 / $2,027.53
| Professional | | $572.23 | $1,051.75 | $2,027.53 |