- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,230.27 / $2,137.96
| Professional | | $1,148.15 | $1,230.27 | $2,137.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,011.87 / $5,011.87
| Facility | | $5,011.87 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $3,467.37 / $4,168.69
| Professional | | $2,290.87 | $3,467.37 | $4,168.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,584.89 / $2,454.71 / $3,388.44
| Professional | | $1,584.89 | $2,454.71 | $3,388.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,011.87 / $5,128.61 / $18,197.01
| Facility | | $5,011.87 | $5,128.61 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $2,290.87 / $5,011.87
| Professional | | $1,445.44 | $2,290.87 | $5,011.87 |