- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,691.53 / $3,467.37 / $3,981.07
| Professional | | $2,691.53 | $3,467.37 | $3,981.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $741.31 / $741.31 / $741.31
| Facility | | $741.31 | $741.31 | $741.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $3,162.28 / $4,265.80
| Professional | | $2,818.38 | $3,162.28 | $4,265.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $707.95 / $707.95 / $707.95
| Facility | | $707.95 | $707.95 | $707.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,090.30 / $4,365.16 / $7,244.36
| Professional | | $3,090.30 | $4,365.16 | $7,244.36 |