- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.15 / $1,288.25 / $3,235.94
| Professional | | $1,148.15 | $1,288.25 | $3,235.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,454.71 / $3,715.35 / $4,365.16
| Professional | | $2,454.71 | $3,715.35 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,778.28 / $2,187.76 / $3,019.95
| Professional | | $1,778.28 | $2,187.76 | $3,019.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,128.61 / $6,309.57 / $18,197.01
| Facility | | $5,128.61 | $6,309.57 | $18,197.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,548.82 / $2,570.40 / $4,677.35
| Professional | | $1,548.82 | $2,570.40 | $4,677.35 |