- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $830.38 / $940.66 / $1,310.01
| Professional | | $830.38 | $940.66 | $1,310.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,416.00 / $2,899.00 / $4,486.00
| Professional | | $2,416.00 | $2,899.00 | $4,486.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $922.01 / $1,559.45 / $2,091.28
| Professional | | $922.01 | $1,559.45 | $2,091.28 |
- 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
- $983.28 / $1,898.73 / $3,410.87
| Professional | | $983.28 | $1,898.73 | $3,410.87 |