- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $553.35 / $759.21 / $1,036.50
| Professional | | $553.35 | $759.21 | $1,036.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,214.00 / $1,457.00 / $1,884.00
| Professional | | $1,214.00 | $1,457.00 | $1,884.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $858.57 / $1,309.48 / $1,901.41
| Professional | | $858.57 | $1,309.48 | $1,901.41 |
- 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
- $1,211.65 / $1,866.89 / $3,218.17
| Professional | | $1,211.65 | $1,866.89 | $3,218.17 |