- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $904.14 / $1,219.13 / $1,657.66
| Professional | | $904.14 | $1,219.13 | $1,657.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,156.08 / $1,360.10 / $2,044.87
| Professional | | $1,156.08 | $1,360.10 | $2,044.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $250.00 / $1,430.95 / $2,350.73
| Professional | | $250.00 | $1,430.95 | $2,350.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,551.00 / $3,630.00 / $7,205.00
| Facility | | $1,551.00 | $3,630.00 | $7,205.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,013.41 / $1,551.69 / $1,954.88
| Professional | | $1,013.41 | $1,551.69 | $1,954.88 |