- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $693.62 / $727.26 / $1,059.00
| Professional | | $693.62 | $727.26 | $1,059.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,941.00 / $2,329.00 / $3,604.00
| Professional | | $1,941.00 | $2,329.00 | $3,604.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $728.44 / $1,263.15 / $1,706.84
| Professional | | $728.44 | $1,263.15 | $1,706.84 |
- 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
- $821.76 / $1,441.81 / $2,954.15
| Professional | | $821.76 | $1,441.81 | $2,954.15 |