- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,707.82 / $7,004.87 / $7,004.87
| Professional | | $1,707.82 | $7,004.87 | $7,004.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,173.66 / $2,173.66 / $2,173.66
| Facility | | $2,173.66 | $2,173.66 | $2,173.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,272.10 / $1,291.44 / $2,173.66
| Professional | | $1,272.10 | $1,291.44 | $2,173.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,120.00 / $1,535.08 / $2,173.66
| Facility | | $1,120.00 | $1,535.08 | $2,173.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,309.79 / $1,878.11 / $2,592.54
| Professional | | $1,309.79 | $1,878.11 | $2,592.54 |
- 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
- $1,854.37 / $2,089.91 / $2,500.42
| Professional | | $1,854.37 | $2,089.91 | $2,500.42 |