- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $939.89 / $954.04 / $1,380.81
| Professional | | $939.89 | $954.04 | $1,380.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,657.00 / $3,188.00 / $4,933.00
| Professional | | $2,657.00 | $3,188.00 | $4,933.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,025.53 / $1,716.67 / $2,382.67
| Professional | | $1,025.53 | $1,716.67 | $2,382.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.50 / $1,915.02 / $3,512.61
| Professional | | $1,018.50 | $1,915.02 | $3,512.61 |