- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,288.25 / $3,630.78
| Professional | | $1,047.13 | $1,288.25 | $3,630.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,467.37 / $4,786.30 / $5,495.41
| Facility | | $3,467.37 | $4,786.30 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,258.93 / $2,570.40
| Professional | | $933.25 | $1,258.93 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Facility | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,000.00 / $1,380.38
| Professional | | $1,000.00 | $1,000.00 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,698.24 / $2,951.21
| Facility | | $1,445.44 | $1,698.24 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,445.44 / $1,995.26
| Professional | | $1,071.52 | $1,445.44 | $1,995.26 |