- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,746.00 / $1,955.03 / $2,932.48
| Professional | | $1,746.00 | $1,955.03 | $2,932.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,373.60 / $1,373.60 / $1,373.60
| Facility | | $1,373.60 | $1,373.60 | $1,373.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,391.00 / $4,069.00 / $6,155.00
| Professional | | $3,391.00 | $4,069.00 | $6,155.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,746.01 / $3,611.64 / $5,122.46
| Professional | | $2,746.01 | $3,611.64 | $5,122.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $788.00 / $788.00 / $3,328.00
| Facility | | $788.00 | $788.00 | $3,328.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,051.57 / $3,844.51 / $6,259.02
| Professional | | $2,051.57 | $3,844.51 | $6,259.02 |