- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,905.46 / $4,570.88
| Professional | | $1,659.59 | $1,905.46 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,162.28 / $3,162.28 / $3,162.28
| Professional | | $3,162.28 | $3,162.28 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $4,786.30 / $6,606.93
| Facility | | $1,995.26 | $4,786.30 | $6,606.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,513.56 / $13,489.63
| Professional | | $1,047.13 | $1,513.56 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $1,621.81
| Facility | | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,513.56 / $3,801.89
| Professional | | $1,047.13 | $1,513.56 | $3,801.89 |