- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $710.89 / $738.67 / $1,104.83
| Professional | | $710.89 | $738.67 | $1,104.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,980.00 / $2,376.00 / $3,677.00
| Professional | | $1,980.00 | $2,376.00 | $3,677.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $738.15 / $1,288.91 / $1,792.60
| Professional | | $738.15 | $1,288.91 | $1,792.60 |
- 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
- $825.92 / $1,451.44 / $3,012.25
| Professional | | $825.92 | $1,451.44 | $3,012.25 |