- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $968.58 / $979.10 / $1,264.82
| Professional | | $968.58 | $979.10 | $1,264.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,007.00 / $2,408.00 / $3,877.00
| Professional | | $2,007.00 | $2,408.00 | $3,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,268.51 / $2,025.25 / $2,511.12
| Professional | | $1,268.51 | $2,025.25 | $2,511.12 |
- 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
- $1,187.56 / $1,996.26 / $3,571.10
| Professional | | $1,187.56 | $1,996.26 | $3,571.10 |