- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,036.25 / $3,901.86 / $5,225.70
| Professional | | $3,036.25 | $3,901.86 | $5,225.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $422.50 / $422.50 / $422.50
| Facility | | $422.50 | $422.50 | $422.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.50 / $4,550.34 / $4,550.34
| Professional | | $422.50 | $4,550.34 | $4,550.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $422.50 / $422.50 / $422.50
| Facility | | $422.50 | $422.50 | $422.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $422.50 / $422.50 / $422.50
| Professional | | $422.50 | $422.50 | $422.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,930.38 / $4,631.04 / $5,421.21
| Professional | | $1,930.38 | $4,631.04 | $5,421.21 |