- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,737.80 / $2,089.30
| Professional | | $1,479.11 | $1,737.80 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,659.59 / $2,951.21
| Professional | | $1,148.15 | $1,659.59 | $2,951.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $10,471.29 / $10,471.29 / $10,471.29
| Facility | | $10,471.29 | $10,471.29 | $10,471.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10,964.78 / $16,595.87 / $16,595.87
| Professional | | $10,964.78 | $16,595.87 | $16,595.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,318.26 / $2,238.72
| Professional | | $933.25 | $1,318.26 | $2,238.72 |