- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $683.13 / $699.72 / $1,043.39
| Professional | | $683.13 | $699.72 | $1,043.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,005.00 / $2,406.00 / $3,724.00
| Professional | | $2,005.00 | $2,406.00 | $3,724.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $784.55 / $1,276.38 / $1,800.43
| Professional | | $784.55 | $1,276.38 | $1,800.43 |
- 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
- $769.27 / $1,431.30 / $2,580.51
| Professional | | $769.27 | $1,431.30 | $2,580.51 |