- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $878.98 / $878.98 / $1,225.39
| Professional | | $878.98 | $878.98 | $1,225.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,270.00 / $3,133.00 / $4,848.00
| Professional | | $2,270.00 | $3,133.00 | $4,848.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,058.54 / $1,491.98 / $2,542.60
| Professional | | $1,058.54 | $1,491.98 | $2,542.60 |
- 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
- $1,493.80 / $2,593.73 / $4,250.39
| Professional | | $1,493.80 | $2,593.73 | $4,250.39 |