- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $845.72 / $933.75 / $1,284.57
| Professional | | $845.72 | $933.75 | $1,284.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,366.00 / $2,839.00 / $4,393.00
| Professional | | $2,366.00 | $2,839.00 | $4,393.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $890.68 / $1,538.62 / $2,122.10
| Professional | | $890.68 | $1,538.62 | $2,122.10 |
- 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
- $1,003.98 / $1,588.04 / $3,614.16
| Professional | | $1,003.98 | $1,588.04 | $3,614.16 |