- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $971.20 / $1,004.62 / $1,504.61
| Professional | | $971.20 | $1,004.62 | $1,504.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,862.00 / $3,434.00 / $5,314.00
| Professional | | $2,862.00 | $3,434.00 | $5,314.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,118.27 / $1,822.35 / $2,563.56
| Professional | | $1,118.27 | $1,822.35 | $2,563.56 |
- 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
- $1,125.90 / $2,028.79 / $4,160.66
| Professional | | $1,125.90 | $2,028.79 | $4,160.66 |