- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,189.34 / $1,233.16 / $6,137.50
| Professional | | $1,189.34 | $1,233.16 | $6,137.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,865.01 / $1,865.01 / $1,865.01
| Facility | | $1,865.01 | $1,865.01 | $1,865.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,298.24 / $1,865.01 / $1,865.01
| Professional | | $1,298.24 | $1,865.01 | $1,865.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $913.11 / $2,063.10 / $2,169.48
| Facility | | $913.11 | $2,063.10 | $2,169.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,135.81 / $1,703.89 / $2,457.69
| Professional | | $1,135.81 | $1,703.89 | $2,457.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,618.75 / $2,031.36 / $3,269.86
| Professional | | $1,618.75 | $2,031.36 | $3,269.86 |