- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $903.69 / $927.27 / $1,376.81
| Professional | | $903.69 | $927.27 | $1,376.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,652.00 / $3,182.00 / $4,924.00
| Professional | | $2,652.00 | $3,182.00 | $4,924.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,041.14 / $1,684.84 / $2,388.98
| Professional | | $1,041.14 | $1,684.84 | $2,388.98 |
- 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
- $1,044.38 / $1,841.40 / $3,911.14
| Professional | | $1,044.38 | $1,841.40 | $3,911.14 |