- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $2,137.96 / $3,235.94
| Professional | | $1,380.38 | $2,137.96 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.17 / $1,659.59 / $7,585.78
| Professional | | $204.17 | $1,659.59 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,630.27 / $4,466.84 / $11,220.18
| Facility | | $2,630.27 | $4,466.84 | $11,220.18 |
- 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
- $1,258.93 / $1,258.93 / $1,258.93
| Facility | | $1,258.93 | $1,258.93 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,513.56 / $3,981.07
| Professional | | $1,047.13 | $1,513.56 | $3,981.07 |