- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,148.15 / $1,548.82
| Professional | | $1,000.00 | $1,148.15 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,019.95 / $4,677.35 / $5,623.41
| Professional | | $3,019.95 | $4,677.35 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,905.46 / $3,548.13
| Professional | | $1,202.26 | $1,905.46 | $3,548.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $3,090.30
| Facility | | $1,288.25 | $1,288.25 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,905.46 / $3,801.89
| Professional | | $1,174.90 | $1,905.46 | $3,801.89 |