- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,023.29 / $2,691.53
| Professional | | $1,000.00 | $1,023.29 | $2,691.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,630.27 / $3,162.28
| Professional | | $2,137.96 | $2,630.27 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,819.70 / $2,398.83
| Professional | | $1,412.54 | $1,819.70 | $2,398.83 |
- 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
- $1,318.26 / $2,089.30 / $3,715.35
| Professional | | $1,318.26 | $2,089.30 | $3,715.35 |