- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $752.81 / $835.61 / $1,141.75
| Professional | | $752.81 | $835.61 | $1,141.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,225.00 / $2,670.00 / $4,130.00
| Professional | | $2,225.00 | $2,670.00 | $4,130.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $871.33 / $1,415.11 / $1,968.11
| Professional | | $871.33 | $1,415.11 | $1,968.11 |
- 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
- $875.93 / $1,458.01 / $3,237.95
| Professional | | $875.93 | $1,458.01 | $3,237.95 |