- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.62 / $571.17 / $859.49
| Professional | | $525.62 | $571.17 | $859.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,623.00 / $1,948.00 / $3,014.00
| Professional | | $1,623.00 | $1,948.00 | $3,014.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $633.04 / $1,037.16 / $1,368.44
| Professional | | $633.04 | $1,037.16 | $1,368.44 |
- 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
- $712.20 / $1,130.23 / $2,251.91
| Professional | | $712.20 | $1,130.23 | $2,251.91 |