- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,937.92 / $8,131.44 / $8,131.44
| Professional | | $1,937.92 | $8,131.44 | $8,131.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,473.36 / $2,473.36 / $2,473.36
| Facility | | $2,473.36 | $2,473.36 | $2,473.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,507.48 / $1,540.36 / $2,473.36
| Professional | | $1,507.48 | $1,540.36 | $2,473.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,120.00 / $1,856.32 / $2,473.36
| Facility | | $1,120.00 | $1,856.32 | $2,473.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,502.01 / $2,127.89 / $2,945.93
| Professional | | $1,502.01 | $2,127.89 | $2,945.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,490.00 / $1,490.00 / $1,490.00
| Facility | | $1,490.00 | $1,490.00 | $1,490.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,259.92 / $2,477.21 / $3,042.20
| Professional | | $2,259.92 | $2,477.21 | $3,042.20 |