- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,560.54 / $1,950.67 / $3,266.76
| Professional | | $1,560.54 | $1,950.67 | $3,266.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $844.22 / $1,107.65 / $1,885.50
| Facility | | $844.22 | $1,107.65 | $1,885.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,194.00 / $5,066.00 / $5,066.00
| Professional | | $1,194.00 | $5,066.00 | $5,066.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,194.00 / $1,194.00 / $1,194.00
| Facility | | $1,194.00 | $1,194.00 | $1,194.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,052.00 / $1,194.00 / $1,459.94
| Professional | | $1,052.00 | $1,194.00 | $1,459.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.00 / $1,005.00 / $1,976.50
| Professional | | $5.00 | $1,005.00 | $1,976.50 |