- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $975.32 / $1,004.95 / $1,494.50
| Professional | | $975.32 | $1,004.95 | $1,494.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,866.00 / $3,439.00 / $5,321.00
| Professional | | $2,866.00 | $3,439.00 | $5,321.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,123.28 / $1,821.48 / $2,570.82
| Professional | | $1,123.28 | $1,821.48 | $2,570.82 |
- 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
- $1,127.26 / $2,019.92 / $4,216.08
| Professional | | $1,127.26 | $2,019.92 | $4,216.08 |