- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.25 / $7,320.60 / $7,320.60
| Professional | | $1,479.25 | $7,320.60 | $7,320.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,256.21 / $2,256.21 / $2,256.21
| Professional | | $2,256.21 | $2,256.21 | $2,256.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,256.21 / $2,256.21 / $2,256.21
| Facility | | $2,256.21 | $2,256.21 | $2,256.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,487.41 / $2,256.21 / $2,392.02
| Professional | | $1,487.41 | $2,256.21 | $2,392.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,108.43 / $2,320.50 / $2,441.44
| Facility | | $1,108.43 | $2,320.50 | $2,441.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,363.88 / $2,046.02 / $2,951.20
| Professional | | $1,363.88 | $2,046.02 | $2,951.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,902.09 / $2,347.26 / $3,931.25
| Professional | | $1,902.09 | $2,347.26 | $3,931.25 |