- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,174.90 / $2,691.53
| Professional | | $1,000.00 | $1,174.90 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,884.03 / $3,467.37
| Professional | | $1,949.84 | $2,884.03 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,737.80 / $1,949.84
| Professional | | $1,122.02 | $1,737.80 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $5,011.87 / $10,471.29
| Facility | | $2,630.27 | $5,011.87 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $2,089.30 / $3,235.94
| Professional | | $1,071.52 | $2,089.30 | $3,235.94 |