- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,796.67 / $1,832.07 / $1,832.07
| Professional | | $1,796.67 | $1,832.07 | $1,832.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $783.43 / $783.43 / $783.43
| Professional | | $783.43 | $783.43 | $783.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,889.03 / $7,909.24 / $8,621.99
| Facility | | $3,889.03 | $7,909.24 | $8,621.99 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,034.66 / $1,969.75 / $3,406.92
| Professional | | $1,034.66 | $1,969.75 | $3,406.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $890.63 / $980.41 / $3,591.22
| Professional | | $890.63 | $980.41 | $3,591.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $626.29 / $688.92 / $876.81
| Professional | | $626.29 | $688.92 | $876.81 |