- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,174.90 / $1,548.82
| Professional | | $891.25 | $1,174.90 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $7,244.36 / $7,244.36
| Facility | | $5,754.40 | $7,244.36 | $7,244.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,230.27 / $1,819.70
| Professional | | $1,000.00 | $1,230.27 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,698.24 / $3,235.94
| Professional | | $1,412.54 | $1,698.24 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,258.93 / $1,548.82
| Professional | | $933.25 | $1,258.93 | $1,548.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,584.89 / $2,818.38
| Professional | | $1,000.00 | $1,584.89 | $2,818.38 |