- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,584.89 / $2,818.38
| Professional | | $1,380.38 | $1,584.89 | $2,818.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,715.35 / $5,623.41 / $5,623.41
| Professional | | $3,715.35 | $5,623.41 | $5,623.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,949.84 / $2,818.38 / $4,466.84
| Professional | | $1,949.84 | $2,818.38 | $4,466.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $8,511.38 / $26,915.35
| Facility | | $8,511.38 | $8,511.38 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,884.03 / $6,165.95
| Professional | | $1,778.28 | $2,884.03 | $6,165.95 |