- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,023.29 / $1,148.15 / $2,041.74
| Professional | | $1,023.29 | $1,148.15 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $3,388.44 / $4,073.80
| Professional | | $2,238.72 | $3,388.44 | $4,073.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $2,137.96 / $3,162.28
| Professional | | $1,258.93 | $2,137.96 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,918.31 / $6,918.31 / $25,703.96
| Facility | | $6,918.31 | $6,918.31 | $25,703.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,995.26 / $4,168.69
| Professional | | $1,096.48 | $1,995.26 | $4,168.69 |