- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,128.53 / $1,813.36 / $1,813.36
| Professional | | $1,128.53 | $1,813.36 | $1,813.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,450.41 / $1,450.41 / $1,450.41
| Facility | | $1,450.41 | $1,450.41 | $1,450.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,232.84 / $1,450.41 / $3,787.50
| Professional | | $1,232.84 | $1,450.41 | $3,787.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.20 / $1,813.36 / $2,059.92
| Facility | | $630.20 | $1,813.36 | $2,059.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,647.59 / $1,647.59 / $1,647.59
| Professional | | $1,647.59 | $1,647.59 | $1,647.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $751.30 / $1,023.01 / $1,667.89
| Professional | | $751.30 | $1,023.01 | $1,667.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,008.13 / $12,155.63 / $12,155.63
| Facility | | $2,008.13 | $12,155.63 | $12,155.63 |