- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,258.93 / $1,445.44
| Professional | | $1,000.00 | $1,258.93 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,819.70 / $1,819.70
| Facility | | $1,659.59 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,513.56 / $1,819.70
| Professional | | $1,513.56 | $1,513.56 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,238.72 / $2,754.23
| Professional | | $1,778.28 | $2,238.72 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,659.59
| Facility | | $1,380.38 | $1,380.38 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $1,698.24 / $4,786.30
| Professional | | $794.33 | $1,698.24 | $4,786.30 |