- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,397.05 / $1,398.60 / $1,551.81
| Professional | | $1,397.05 | $1,398.60 | $1,551.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,448.72 / $1,704.38 / $2,901.78
| Professional | | $1,448.72 | $1,704.38 | $2,901.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.00 / $1,917.08 / $2,856.64
| Professional | | $350.00 | $1,917.08 | $2,856.64 |
- 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 / $1,965.40 / $3,027.09
| Professional | | $798.25 | $1,965.40 | $3,027.09 |