- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $692.52 / $709.14 / $1,055.08
| Professional | | $692.52 | $709.14 | $1,055.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,028.00 / $2,434.00 / $3,764.00
| Professional | | $2,028.00 | $2,434.00 | $3,764.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.53 / $1,289.77 / $1,827.52
| Professional | | $794.53 | $1,289.77 | $1,827.52 |
- 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
- $813.19 / $1,575.56 / $2,983.20
| Professional | | $813.19 | $1,575.56 | $2,983.20 |