- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.71 / $1,017.85 / $1,525.44
| Professional | | $981.71 | $1,017.85 | $1,525.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,896.00 / $3,475.00 / $5,377.00
| Professional | | $2,896.00 | $3,475.00 | $5,377.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,133.18 / $1,845.40 / $2,463.38
| Professional | | $1,133.18 | $1,845.40 | $2,463.38 |
- 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
- $1,137.34 / $2,036.80 / $4,218.71
| Professional | | $1,137.34 | $2,036.80 | $4,218.71 |