- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $674.21 / $701.62 / $1,046.23
| Professional | | $674.21 | $701.62 | $1,046.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,011.00 / $2,413.00 / $3,734.00
| Professional | | $2,011.00 | $2,413.00 | $3,734.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $787.11 / $1,280.08 / $1,738.82
| Professional | | $787.11 | $1,280.08 | $1,738.82 |
- 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
- $792.04 / $1,558.84 / $2,873.65
| Professional | | $792.04 | $1,558.84 | $2,873.65 |