- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,819.70 / $1,905.46
| Professional | | $1,479.11 | $1,819.70 | $1,905.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $2,754.23
| Professional | | $2,754.23 | $2,754.23 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,238.72 / $2,951.21
| Facility | | $1,778.28 | $2,238.72 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $10,964.78
| Professional | | $933.25 | $1,318.26 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $1,445.44
| Facility | | $1,445.44 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $3,311.31
| Professional | | $933.25 | $1,318.26 | $3,311.31 |