- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $998.46 / $1,355.33 / $1,457.30
| Professional | | $998.46 | $1,355.33 | $1,457.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,230.93 / $4,363.79 / $5,166.22
| Facility | | $3,230.93 | $4,363.79 | $5,166.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,093.70 / $1,286.71 / $2,066.52
| Professional | | $1,093.70 | $1,286.71 | $2,066.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,320.62 / $1,800.00 / $1,800.00
| Facility | | $1,320.62 | $1,800.00 | $1,800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,314.00 / $1,800.00 / $1,800.00
| Professional | | $1,314.00 | $1,800.00 | $1,800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,073.13 / $1,405.43 / $1,900.09
| Professional | | $1,073.13 | $1,405.43 | $1,900.09 |