- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $690.06 / $717.31 / $1,068.03
| Professional | | $690.06 | $717.31 | $1,068.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,049.00 / $2,459.00 / $3,804.00
| Professional | | $2,049.00 | $2,459.00 | $3,804.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $801.82 / $1,303.51 / $1,804.51
| Professional | | $801.82 | $1,303.51 | $1,804.51 |
- 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
- $806.31 / $1,446.97 / $2,976.61
| Professional | | $806.31 | $1,446.97 | $2,976.61 |