- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,191.90 / $1,580.19 / $1,666.78
| Professional | | $1,191.90 | $1,580.19 | $1,666.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $9,661.98 / $9,661.98 / $12,000.61
| Facility | | $9,661.98 | $9,661.98 | $12,000.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,401.82 / $2,348.41 / $3,044.34
| Professional | | $1,401.82 | $2,348.41 | $3,044.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,404.02 / $1,988.04 / $3,044.34
| Professional | | $1,404.02 | $1,988.04 | $3,044.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.98 / $1,912.11 / $5,558.63
| Professional | | $1,659.98 | $1,912.11 | $5,558.63 |