- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,905.46 / $2,290.87
| Professional | | $1,288.25 | $1,905.46 | $2,290.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,079.46 / $7,079.46 / $7,079.46
| Professional | | $7,079.46 | $7,079.46 | $7,079.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,288.25 / $1,348.96
| Facility | | $1,288.25 | $1,288.25 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,949.84 / $2,818.38
| Professional | | $1,698.24 | $1,949.84 | $2,818.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,022.64 / $12,022.64 / $16,595.87
| Facility | | $12,022.64 | $12,022.64 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,819.70 / $3,548.13
| Professional | | $1,380.38 | $1,819.70 | $3,548.13 |