- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,096.48 / $1,230.27
| Professional | | $1,000.00 | $1,096.48 | $1,230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Facility | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $1,905.46 / $1,905.46
| Professional | | $1,905.46 | $1,905.46 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,778.28 / $3,981.07
| Facility | | $1,318.26 | $1,778.28 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,778.28 / $3,981.07
| Professional | | $1,318.26 | $1,778.28 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,174.90 / $1,905.46 / $2,884.03
| Facility | | $1,174.90 | $1,905.46 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,174.90 / $1,905.46
| Professional | | $79.43 | $1,174.90 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $467.74 / $467.74 / $1,122.02
| Professional | | $467.74 | $467.74 | $1,122.02 |