- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,262.29 / $1,654.79 / $6,185.11
| Professional | | $1,262.29 | $1,654.79 | $6,185.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,880.26 / $1,880.26 / $1,880.26
| Professional | | $1,880.26 | $1,880.26 | $1,880.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,880.26 / $1,880.26 / $1,880.26
| Facility | | $1,880.26 | $1,880.26 | $1,880.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $989.46 / $1,880.26 / $1,992.19
| Professional | | $989.46 | $1,880.26 | $1,992.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $930.35 / $1,279.23 / $1,880.26
| Facility | | $930.35 | $1,279.23 | $1,880.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,136.78 / $1,880.26 / $2,459.80
| Professional | | $1,136.78 | $1,880.26 | $2,459.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,608.81 / $1,934.59 / $2,190.71
| Professional | | $1,608.81 | $1,934.59 | $2,190.71 |