- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,412.54 / $1,621.81
| Professional | | $1,000.00 | $1,412.54 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,819.70 / $1,819.70
| Facility | | $1,737.80 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,862.09
| Professional | | $1,318.26 | $1,318.26 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,862.09 / $2,290.87 / $3,090.30
| Professional | | $1,862.09 | $2,290.87 | $3,090.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,412.54 / $1,862.09
| Facility | | $1,348.96 | $1,412.54 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,778.28 / $4,897.79
| Professional | | $812.83 | $1,778.28 | $4,897.79 |