- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,692.68 / $1,857.86 / $8,363.51
| Professional | | $1,692.68 | $1,857.86 | $8,363.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,552.76 / $2,552.76 / $2,552.76
| Professional | | $2,552.76 | $2,552.76 | $2,552.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,552.76 / $2,552.76 / $2,552.76
| Facility | | $2,552.76 | $2,552.76 | $2,552.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,012.14 / $2,552.76 / $2,552.76
| Professional | | $2,012.14 | $2,552.76 | $2,552.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,552.76 / $3,265.60 / $3,388.30
| Facility | | $2,552.76 | $3,265.60 | $3,388.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,570.92 / $2,225.50 / $3,399.20
| Professional | | $1,570.92 | $2,225.50 | $3,399.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,507.44 / $2,893.20 / $4,471.45
| Professional | | $2,507.44 | $2,893.20 | $4,471.45 |