- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,262.89 / $1,560.54 / $1,950.67
| Professional | | $1,262.89 | $1,560.54 | $1,950.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $804.49 / $1,272.82 / $1,548.50
| Facility | | $804.49 | $1,272.82 | $1,548.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,066.00 / $5,066.00 / $5,066.00
| Professional | | $5,066.00 | $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 / $1,159.00 / $1,459.94
| Professional | | $1,052.00 | $1,159.00 | $1,459.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $838.22 / $961.21 / $961.21
| Professional | | $838.22 | $961.21 | $961.21 |