- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,230.27 / $1,348.96 / $2,344.23
| Professional | | $1,230.27 | $1,348.96 | $2,344.23 |
- 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
- $2,570.40 / $3,890.45 / $4,677.35
| Professional | | $2,570.40 | $3,890.45 | $4,677.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,621.81 / $2,454.71 / $3,715.35
| Professional | | $1,621.81 | $2,454.71 | $3,715.35 |
- 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
- $1,479.11 / $2,454.71 / $5,248.07
| Professional | | $1,479.11 | $2,454.71 | $5,248.07 |