- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $663.26 / $749.55 / $820.30
| Professional | | $663.26 | $749.55 | $820.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,374.00 / $3,838.00 / $4,210.00
| Professional | | $2,374.00 | $3,838.00 | $4,210.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $883.57 / $1,087.90 / $1,678.79
| Professional | | $883.57 | $1,087.90 | $1,678.79 |
- 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
- $892.45 / $1,948.35 / $2,785.91
| Professional | | $892.45 | $1,948.35 | $2,785.91 |