- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $879.25 / $895.04 / $1,324.82
| Professional | | $879.25 | $895.04 | $1,324.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,543.00 / $3,052.00 / $4,722.00
| Professional | | $2,543.00 | $3,052.00 | $4,722.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $993.71 / $1,624.33 / $2,309.80
| Professional | | $993.71 | $1,624.33 | $2,309.80 |
- 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
- $1,021.02 / $1,803.16 / $3,789.72
| Professional | | $1,021.02 | $1,803.16 | $3,789.72 |