- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $746.71 / $754.67 / $1,110.83
| Professional | | $746.71 | $754.67 | $1,110.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,126.00 / $2,551.00 / $3,947.00
| Professional | | $2,126.00 | $2,551.00 | $3,947.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $865.68 / $1,353.12 / $1,931.21
| Professional | | $865.68 | $1,353.12 | $1,931.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.50 / $1,434.00 / $3,160.30
| Professional | | $836.50 | $1,434.00 | $3,160.30 |