- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $867.78 / $873.29 / $1,292.80
| Professional | | $867.78 | $873.29 | $1,292.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,483.00 / $2,980.00 / $4,610.00
| Professional | | $2,483.00 | $2,980.00 | $4,610.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $972.56 / $1,580.49 / $2,178.73
| Professional | | $972.56 | $1,580.49 | $2,178.73 |
- 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
- $1,026.03 / $1,925.21 / $3,710.53
| Professional | | $1,026.03 | $1,925.21 | $3,710.53 |