- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.61 / $900.71 / $1,132.92
| Professional | | $891.61 | $900.71 | $1,132.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,714.00 / $2,057.00 / $3,113.00
| Professional | | $1,714.00 | $2,057.00 | $3,113.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,226.68 / $1,801.43 / $2,471.73
| Professional | | $1,226.68 | $1,801.43 | $2,471.73 |
- 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
- $1,117.45 / $1,796.35 / $3,131.70
| Professional | | $1,117.45 | $1,796.35 | $3,131.70 |