- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,441.91 / $1,826.33 / $6,997.60
| Professional | | $1,441.91 | $1,826.33 | $6,997.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,930.29 / $1,930.29 / $2,270.92
| Professional | | $1,930.29 | $1,930.29 | $2,270.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,270.40 / $2,270.40 / $2,270.40
| Facility | | $2,270.40 | $2,270.40 | $2,270.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,203.10 / $2,270.40 / $2,451.96
| Professional | | $1,203.10 | $2,270.40 | $2,451.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,119.48 / $1,455.78 / $2,270.40
| Facility | | $1,119.48 | $1,455.78 | $2,270.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,360.32 / $2,267.34 / $2,943.50
| Professional | | $1,360.32 | $2,267.34 | $2,943.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,040.50 / $2,240.55 / $2,535.82
| Professional | | $2,040.50 | $2,240.55 | $2,535.82 |