- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $992.00 / $992.36 / $1,515.12
| Professional | | $992.00 | $992.36 | $1,515.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,804.00 / $3,365.00 / $5,206.00
| Professional | | $2,804.00 | $3,365.00 | $5,206.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,072.02 / $1,808.50 / $2,437.55
| Professional | | $1,072.02 | $1,808.50 | $2,437.55 |
- 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
- $1,075.52 / $1,902.00 / $3,699.79
| Professional | | $1,075.52 | $1,902.00 | $3,699.79 |