- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,030.38 / $1,163.74 / $1,674.12
| Professional | | $1,030.38 | $1,163.74 | $1,674.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,075.96 / $1,265.83 / $2,125.88
| Professional | | $1,075.96 | $1,265.83 | $2,125.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.00 / $1,429.35 / $2,101.17
| Professional | | $350.00 | $1,429.35 | $2,101.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,596.00 / $7,457.00 / $12,945.00
| Facility | | $4,596.00 | $7,457.00 | $12,945.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $798.25 / $1,445.12 / $2,227.11
| Professional | | $798.25 | $1,445.12 | $2,227.11 |