- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,698.24 / $1,862.09
| Professional | | $1,445.44 | $1,698.24 | $1,862.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,290.87 / $2,290.87 / $2,290.87
| Professional | | $2,290.87 | $2,290.87 | $2,290.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $54.95 / $54.95 / $5,495.41
| Facility | | $54.95 | $54.95 | $5,495.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,489.63 / $13,489.63 / $13,489.63
| Professional | | $13,489.63 | $13,489.63 | $13,489.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,630.27 / $2,951.21
| Facility | | $1,737.80 | $2,630.27 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,737.80 / $2,398.83
| Professional | | $1,318.26 | $1,737.80 | $2,398.83 |