- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,230.27 / $1,621.81
| Professional | | $1,000.00 | $1,230.27 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,819.70
| Facility | | $1,288.25 | $1,288.25 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,041.74 / $2,884.03
| Professional | | $1,288.25 | $2,041.74 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,344.23 / $2,454.71
| Professional | | $2,344.23 | $2,344.23 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,344.23 / $2,691.53
| Professional | | $1,380.38 | $2,344.23 | $2,691.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,047.13 / $1,288.25
| Facility | | $1,023.29 | $1,047.13 | $1,288.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,737.80 / $2,511.89
| Professional | | $1,230.27 | $1,737.80 | $2,511.89 |