- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,103.08 / $1,770.06 / $2,411.38
| Professional | | $1,103.08 | $1,770.06 | $2,411.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,253.82 / $1,886.64 / $1,984.08
| Professional | | $1,253.82 | $1,886.64 | $1,984.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,208.78 / $1,208.78 / $1,208.78
| Facility | | $1,208.78 | $1,208.78 | $1,208.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.01 / $1,208.78 / $1,245.04
| Professional | | $200.01 | $1,208.78 | $1,245.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.52 / $1,770.06 / $12,092.66
| Facility | | $269.52 | $1,770.06 | $12,092.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.57 / $1,243.16 / $2,235.76
| Professional | | $880.57 | $1,243.16 | $2,235.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $945.19 / $1,228.74 / $2,185.98
| Professional | | $945.19 | $1,228.74 | $2,185.98 |