- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,661.55 / $1,750.17 / $1,971.71
| Professional | | $1,661.55 | $1,750.17 | $1,971.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,661.55 / $3,101.56 / $4,364.34
| Professional | | $1,661.55 | $3,101.56 | $4,364.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,658.48 / $2,658.48 / $2,658.48
| Facility | | $2,658.48 | $2,658.48 | $2,658.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,678.23 / $10,678.23 / $10,678.23
| Professional | | $10,678.23 | $10,678.23 | $10,678.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,854.80 / $5,427.73 / $10,523.15
| Facility | | $3,854.80 | $5,427.73 | $10,523.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $11,032.69 / $11,032.69 / $16,615.50
| Professional | | $11,032.69 | $11,032.69 | $16,615.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $930.47 / $1,329.24 / $2,215.40
| Professional | | $930.47 | $1,329.24 | $2,215.40 |