- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $647.91 / $687.28 / $1,000.09
| Professional | | $647.91 | $687.28 | $1,000.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,835.00 / $2,202.00 / $3,407.00
| Professional | | $1,835.00 | $2,202.00 | $3,407.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $698.44 / $1,186.13 / $1,698.69
| Professional | | $698.44 | $1,186.13 | $1,698.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $5,188.00 / $18,767.00
| Facility | | $5,188.00 | $5,188.00 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $790.44 / $1,280.92 / $2,692.81
| Professional | | $790.44 | $1,280.92 | $2,692.81 |