- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $897.27 / $915.80 / $1,432.74
| Professional | | $897.27 | $915.80 | $1,432.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,558.00 / $3,070.00 / $4,750.00
| Professional | | $2,558.00 | $3,070.00 | $4,750.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $969.27 / $1,615.42 / $2,172.75
| Professional | | $969.27 | $1,615.42 | $2,172.75 |
- 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
- $1,092.88 / $1,779.12 / $3,582.48
| Professional | | $1,092.88 | $1,779.12 | $3,582.48 |