- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $951.88 / $957.43 / $1,401.28
| Professional | | $951.88 | $957.43 | $1,401.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,703.00 / $3,244.00 / $5,018.00
| Professional | | $2,703.00 | $3,244.00 | $5,018.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,042.99 / $1,747.76 / $2,475.82
| Professional | | $1,042.99 | $1,747.76 | $2,475.82 |
- 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
- $1,078.33 / $1,861.46 / $4,274.17
| Professional | | $1,078.33 | $1,861.46 | $4,274.17 |