- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,659.59 / $4,365.16
| Professional | | $1,445.44 | $1,659.59 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $5,370.32 / $5,370.32
| Professional | | $4,897.79 | $5,370.32 | $5,370.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,344.23 / $2,951.21 / $4,168.69
| Professional | | $2,344.23 | $2,951.21 | $4,168.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $5,128.61 / $18,197.01
| Facility | | $5,128.61 | $5,128.61 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $3,467.37 / $6,165.95
| Professional | | $2,041.74 | $3,467.37 | $6,165.95 |