- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $788.13 / $854.94 / $1,196.77
| Professional | | $788.13 | $854.94 | $1,196.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,205.00 / $2,646.00 / $4,093.00
| Professional | | $2,205.00 | $2,646.00 | $4,093.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $830.34 / $1,433.17 / $1,998.23
| Professional | | $830.34 | $1,433.17 | $1,998.23 |
- 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
- $828.80 / $1,466.30 / $3,418.78
| Professional | | $828.80 | $1,466.30 | $3,418.78 |