- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,318.26 / $1,412.54
| Professional | | $1,318.26 | $1,318.26 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $2,754.23 / $3,467.37
| Professional | | $2,754.23 | $2,754.23 | $3,467.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $11,220.18 / $11,220.18 / $11,220.18
| Facility | | $11,220.18 | $11,220.18 | $11,220.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $13,803.84 / $14,125.38 / $14,125.38
| Professional | | $13,803.84 | $14,125.38 | $14,125.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $676.08 / $1,174.90 / $1,348.96
| Facility | | $676.08 | $1,174.90 | $1,348.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $891.25 / $1,348.96
| Professional | | $588.84 | $891.25 | $1,348.96 |