- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,258.93 / $1,698.24
| Professional | | $1,122.02 | $1,258.93 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,311.31 / $5,128.61 / $6,025.60
| Professional | | $3,311.31 | $5,128.61 | $6,025.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,089.30 / $3,890.45
| Professional | | $1,288.25 | $2,089.30 | $3,890.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,511.38 / $9,549.93 / $26,915.35
| Facility | | $8,511.38 | $9,549.93 | $26,915.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,137.96 / $4,365.16
| Professional | | $1,318.26 | $2,137.96 | $4,365.16 |