- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,275.40 / $2,396.75 / $2,700.14
| Professional | | $2,275.40 | $2,396.75 | $2,700.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,275.40 / $4,247.39 / $5,976.70
| Professional | | $2,275.40 | $4,247.39 | $5,976.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,640.63 / $3,640.63 / $3,640.63
| Facility | | $3,640.63 | $3,640.63 | $3,640.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14,623.21 / $14,623.21 / $14,623.21
| Professional | | $14,623.21 | $14,623.21 | $14,623.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,278.92 / $7,432.96 / $14,410.84
| Facility | | $5,278.92 | $7,432.96 | $14,410.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $15,108.62 / $15,108.62 / $22,753.95
| Professional | | $15,108.62 | $15,108.62 | $22,753.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,274.22 / $1,820.32 / $3,033.86
| Professional | | $1,274.22 | $1,820.32 | $3,033.86 |