- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,479.11 / $3,801.89
| Professional | | $1,348.96 | $1,479.11 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,884.03 / $4,265.80 / $5,128.61
| Professional | | $2,884.03 | $4,265.80 | $5,128.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,570.40 / $3,548.13
| Professional | | $1,905.46 | $2,570.40 | $3,548.13 |
- 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
- $1,621.81 / $2,951.21 / $5,011.87
| Professional | | $1,621.81 | $2,951.21 | $5,011.87 |