- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,513.56 / $3,162.28
| Professional | | $1,380.38 | $1,513.56 | $3,162.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,570.40 / $3,801.89 / $4,570.88
| Professional | | $2,570.40 | $3,801.89 | $4,570.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,513.56 / $2,398.83 / $2,691.53
| Professional | | $1,513.56 | $2,398.83 | $2,691.53 |
- 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 / $2,754.23 / $4,365.16
| Professional | | $1,445.44 | $2,754.23 | $4,365.16 |