- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $656.74 / $656.74 / $656.74
| Professional | | $656.74 | $656.74 | $656.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,187.00 / $1,424.00 / $2,080.00
| Professional | | $1,187.00 | $1,424.00 | $2,080.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $889.87 / $1,100.82 / $1,546.23
| Professional | | $889.87 | $1,100.82 | $1,546.23 |
- 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
- $781.13 / $1,727.23 / $2,855.15
| Professional | | $781.13 | $1,727.23 | $2,855.15 |