- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $869.57 / $898.20 / $1,032.71
| Professional | | $869.57 | $898.20 | $1,032.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,494.00 / $1,992.00 / $2,366.00
| Professional | | $1,494.00 | $1,992.00 | $2,366.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $979.56 / $1,304.13 / $1,816.18
| Professional | | $979.56 | $1,304.13 | $1,816.18 |
- 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
- $1,058.24 / $1,738.50 / $2,850.11
| Professional | | $1,058.24 | $1,738.50 | $2,850.11 |