- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,949.16 / $2,949.16 / $33,645.69
| Professional | | $2,949.16 | $2,949.16 | $33,645.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,037.58 / $1,342.81 / $8,973.28
| Professional | | $1,037.58 | $1,342.81 | $8,973.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $848.67 / $1,495.81 / $12,331.49
| Professional | | $848.67 | $1,495.81 | $12,331.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $527.66 / $5,030.20 / $8,551.34
| Facility | | $527.66 | $5,030.20 | $8,551.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,190.54 / $10,087.96 / $13,228.87
| Professional | | $5,190.54 | $10,087.96 | $13,228.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,340.87 / $10,550.57 / $13,228.87
| Professional | | $6,340.87 | $10,550.57 | $13,228.87 |