- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $613.16 / $678.21 / $919.08
| Professional | | $613.16 | $678.21 | $919.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,755.00 / $2,106.00 / $3,259.00
| Professional | | $1,755.00 | $2,106.00 | $3,259.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $686.04 / $1,117.91 / $1,545.06
| Professional | | $686.04 | $1,117.91 | $1,545.06 |
- 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
- $774.52 / $1,236.54 / $2,509.30
| Professional | | $774.52 | $1,236.54 | $2,509.30 |