- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $627.46 / $627.46 / $747.54
| Professional | | $627.46 | $627.46 | $747.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,841.00 / $2,976.00 / $3,507.00
| Professional | | $1,841.00 | $2,976.00 | $3,507.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $738.31 / $959.80 / $1,402.78
| Professional | | $738.31 | $959.80 | $1,402.78 |
- 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
- $750.82 / $1,455.74 / $2,358.17
| Professional | | $750.82 | $1,455.74 | $2,358.17 |