- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.82 / $1,176.47 / $6,664.34
| Professional | | $1,148.82 | $1,176.47 | $6,664.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,200.46 / $2,200.46 / $2,200.46
| Professional | | $2,200.46 | $2,200.46 | $2,200.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,200.46 / $2,200.46 / $2,200.46
| Facility | | $2,200.46 | $2,200.46 | $2,200.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,329.26 / $2,200.46 / $2,200.46
| Professional | | $1,329.26 | $2,200.46 | $2,200.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,075.06 / $2,174.54 / $2,200.46
| Facility | | $1,075.06 | $2,174.54 | $2,200.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,297.24 / $1,946.05 / $2,807.00
| Professional | | $1,297.24 | $1,946.05 | $2,807.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,791.64 / $2,139.50 / $3,125.85
| Professional | | $1,791.64 | $2,139.50 | $3,125.85 |