- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $963.55 / $994.57 / $1,433.08
| Professional | | $963.55 | $994.57 | $1,433.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,758.00 / $3,310.00 / $5,120.00
| Professional | | $2,758.00 | $3,310.00 | $5,120.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,081.16 / $1,753.95 / $2,524.15
| Professional | | $1,081.16 | $1,753.95 | $2,524.15 |
- 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
- $1,173.38 / $1,941.66 / $4,243.80
| Professional | | $1,173.38 | $1,941.66 | $4,243.80 |