- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.46 / $2,630.27 / $3,548.13
| Professional | | $1,905.46 | $2,630.27 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,265.80 / $4,265.80 / $4,265.80
| Professional | | $4,265.80 | $4,265.80 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $3,801.89
| Facility | | $2,754.23 | $2,754.23 | $3,801.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,951.21
| Professional | | $2,041.74 | $2,041.74 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,073.80 / $5,128.61 / $5,888.44
| Professional | | $4,073.80 | $5,128.61 | $5,888.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,454.71 / $2,511.89 / $3,548.13
| Facility | | $2,454.71 | $2,511.89 | $3,548.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,819.70 / $3,890.45 / $10,964.78
| Professional | | $1,819.70 | $3,890.45 | $10,964.78 |