- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $4,677.35
| Professional | | $2,041.74 | $2,041.74 | $4,677.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $1,445.44
| Facility | | $1,445.44 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.21 / $1,445.44 / $1,905.46
| Professional | | $186.21 | $1,445.44 | $1,905.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.17 / $257.04 / $2,630.27
| Facility | | $204.17 | $257.04 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $1,445.44 / $2,884.03
| Professional | | $79.43 | $1,445.44 | $2,884.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $87.10 / $870.96 / $1,737.80
| Facility | | $87.10 | $870.96 | $1,737.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,000.00 / $1,096.48 / $1,122.02
| Professional | | $1,000.00 | $1,096.48 | $1,122.02 |