- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,388.44 / $4,168.69 / $5,248.07
| Professional | | $3,388.44 | $4,168.69 | $5,248.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,000.00
| Facility | | $1,000.00 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $588.84 / $588.84
| Professional | | $588.84 | $588.84 | $588.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,162.28 / $4,265.80 / $4,265.80
| Facility | | $3,162.28 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $457.09 / $3,630.78 / $4,265.80
| Professional | | $457.09 | $3,630.78 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.78 / $501.19 / $3,890.45
| Facility | | $218.78 | $501.19 | $3,890.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $2,754.23 / $5,128.61
| Professional | | $1,479.11 | $2,754.23 | $5,128.61 |