- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $797.82 / $810.26 / $1,041.70
| Professional | | $797.82 | $810.26 | $1,041.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,529.00 / $1,835.00 / $2,776.00
| Professional | | $1,529.00 | $1,835.00 | $2,776.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,077.93 / $1,616.90 / $2,218.89
| Professional | | $1,077.93 | $1,616.90 | $2,218.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,188.00 / $5,188.00 / $18,767.00
| Facility | | $5,188.00 | $5,188.00 | $18,767.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $903.35 / $1,551.05 / $2,733.91
| Professional | | $903.35 | $1,551.05 | $2,733.91 |