- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,473.24 / $1,927.40 / $2,126.78
| Professional | | $1,473.24 | $1,927.40 | $2,126.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.26 / $336.26 / $2,215.40
| Professional | | $336.26 | $336.26 | $2,215.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,101.56 / $3,212.33 / $5,316.96
| Facility | | $3,101.56 | $3,212.33 | $5,316.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $12,470.38 / $12,470.38 / $12,470.38
| Professional | | $12,470.38 | $12,470.38 | $12,470.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,993.86 / $2,215.40 / $3,101.56
| Professional | | $1,993.86 | $2,215.40 | $3,101.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.47 / $1,329.24 / $3,131.91
| Professional | | $930.47 | $1,329.24 | $3,131.91 |