- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $888.96 / $898.96 / $1,117.92
| Professional | | $888.96 | $898.96 | $1,117.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,739.00 / $2,087.00 / $3,156.00
| Professional | | $1,739.00 | $2,087.00 | $3,156.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,166.83 / $1,777.92 / $2,486.21
| Professional | | $1,166.83 | $1,777.92 | $2,486.21 |
- 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
- $965.59 / $1,743.41 / $2,762.50
| Professional | | $965.59 | $1,743.41 | $2,762.50 |