- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,778.28 / $2,570.40
| Professional | | $1,047.13 | $1,778.28 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Professional | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,890.45 / $7,762.47 / $8,511.38
| Facility | | $3,890.45 | $7,762.47 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,995.26 / $3,090.30
| Professional | | $1,148.15 | $1,995.26 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,230.27 / $3,388.44
| Professional | | $1,047.13 | $1,230.27 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $794.33
| Facility | | $794.33 | $794.33 | $794.33 |