- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,380.38 / $4,466.84
| Professional | | $1,000.00 | $1,380.38 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,168.69 / $5,754.40 / $6,760.83
| Facility | | $4,168.69 | $5,754.40 | $6,760.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,513.56 / $3,090.30
| Professional | | $1,148.15 | $1,513.56 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,659.59 / $1,659.59
| Facility | | $1,513.56 | $1,659.59 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,096.48 / $1,513.56
| Professional | | $1,096.48 | $1,096.48 | $1,513.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,412.54 / $3,090.30
| Facility | | $1,122.02 | $1,412.54 | $3,090.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,548.82 / $2,398.83
| Professional | | $1,148.15 | $1,548.82 | $2,398.83 |