- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,104.51 / $3,208.57
| Professional | | $1,000.00 | $1,104.51 | $3,208.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,442.92 / $2,442.92 / $2,442.92
| Facility | | $2,442.92 | $2,442.92 | $2,442.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $835.20 / $835.20 / $2,572.60
| Facility | | $835.20 | $835.20 | $2,572.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,121.44 / $1,121.44 / $1,121.44
| Professional | | $1,121.44 | $1,121.44 | $1,121.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $835.20 / $835.20 / $2,572.60
| Facility | | $835.20 | $835.20 | $2,572.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $324.35 / $324.35 / $1,121.44
| Professional | | $324.35 | $324.35 | $1,121.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.58 / $499.00 / $1,152.89
| Professional | | $209.58 | $499.00 | $1,152.89 |