- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $761.03 / $777.71 / $1,153.34
| Professional | | $761.03 | $777.71 | $1,153.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,140.00 / $2,568.00 / $3,973.00
| Professional | | $2,140.00 | $2,568.00 | $3,973.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $808.91 / $1,386.34 / $1,973.08
| Professional | | $808.91 | $1,386.34 | $1,973.08 |
- 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
- $858.12 / $1,500.83 / $3,467.65
| Professional | | $858.12 | $1,500.83 | $3,467.65 |