- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $900.28 / $927.60 / $1,416.14
| Professional | | $900.28 | $927.60 | $1,416.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,622.00 / $3,146.00 / $4,868.00
| Professional | | $2,622.00 | $3,146.00 | $4,868.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,011.74 / $1,678.98 / $2,338.94
| Professional | | $1,011.74 | $1,678.98 | $2,338.94 |
- 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
- $1,028.42 / $1,845.35 / $3,851.77
| Professional | | $1,028.42 | $1,845.35 | $3,851.77 |