- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $888.28 / $909.77 / $1,355.86
| Professional | | $888.28 | $909.77 | $1,355.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,512.00 / $3,014.00 / $4,664.00
| Professional | | $2,512.00 | $3,014.00 | $4,664.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $960.23 / $1,619.71 / $2,179.11
| Professional | | $960.23 | $1,619.71 | $2,179.11 |
- 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
- $1,011.93 / $1,790.47 / $3,449.15
| Professional | | $1,011.93 | $1,790.47 | $3,449.15 |