- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $643.38 / $683.27 / $959.08
| Professional | | $643.38 | $683.27 | $959.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,043.00 / $2,452.00 / $3,792.00
| Professional | | $2,043.00 | $2,452.00 | $3,792.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $798.49 / $1,300.70 / $1,692.83
| Professional | | $798.49 | $1,300.70 | $1,692.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $5,606.00
| Facility | | $1,275.00 | $1,275.00 | $5,606.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $804.27 / $1,314.50 / $2,919.83
| Professional | | $804.27 | $1,314.50 | $2,919.83 |