- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.48 / $1,513.56 / $3,467.37
| Professional | | $1,096.48 | $1,513.56 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,897.79 / $7,943.28 / $7,943.28
| Professional | | $4,897.79 | $7,943.28 | $7,943.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,258.93 / $1,698.24 / $2,454.71
| Professional | | $1,258.93 | $1,698.24 | $2,454.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,235.94 / $4,168.69 / $14,125.38
| Facility | | $3,235.94 | $4,168.69 | $14,125.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $2,454.71 / $4,073.80
| Professional | | $1,288.25 | $2,454.71 | $4,073.80 |