- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.63 / $812.63 / $3,870.00
| Professional | | $812.63 | $812.63 | $3,870.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,213.00 / $1,682.00 / $2,018.00
| Professional | | $1,213.00 | $1,682.00 | $2,018.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $742.32 / $1,100.13 / $1,650.20
| Professional | | $742.32 | $1,100.13 | $1,650.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $902.87 / $1,402.39 / $2,338.61
| Professional | | $902.87 | $1,402.39 | $2,338.61 |