- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $491.63 / $696.86 / $1,054.18
| Professional | | $491.63 | $696.86 | $1,054.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,091.00 / $2,509.00 / $3,882.00
| Professional | | $2,091.00 | $2,509.00 | $3,882.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $838.75 / $1,343.52 / $2,741.79
| Professional | | $838.75 | $1,343.52 | $2,741.79 |
- 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
- $768.97 / $1,357.87 / $3,395.90
| Professional | | $768.97 | $1,357.87 | $3,395.90 |