- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,205.54 / $1,323.34 / $6,824.14
| Professional | | $1,205.54 | $1,323.34 | $6,824.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,073.76 / $2,073.76 / $2,488.51
| Professional | | $2,073.76 | $2,073.76 | $2,488.51 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,073.76 / $2,073.76 / $2,073.76
| Facility | | $2,073.76 | $2,073.76 | $2,073.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,296.45 / $2,073.76 / $3,845.79
| Professional | | $1,296.45 | $2,073.76 | $3,845.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,216.06 / $1,876.45 / $2,568.58
| Facility | | $1,216.06 | $1,876.45 | $2,568.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,367.92 / $2,117.98 / $3,529.31
| Professional | | $1,367.92 | $2,117.98 | $3,529.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,974.58 / $2,325.00 / $2,905.60
| Professional | | $1,974.58 | $2,325.00 | $2,905.60 |