- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,839.72 / $3,145.15 / $4,076.38
| Professional | | $2,839.72 | $3,145.15 | $4,076.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $647.41 / $647.41 / $647.41
| Facility | | $647.41 | $647.41 | $647.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $411.70 / $411.70 / $411.70
| Professional | | $411.70 | $411.70 | $411.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,248.38 / $3,248.38 / $5,117.10
| Facility | | $3,248.38 | $3,248.38 | $5,117.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $415.13 / $3,248.38 / $3,248.38
| Professional | | $415.13 | $3,248.38 | $3,248.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,730.84 / $2,596.26 / $5,025.85
| Professional | | $1,730.84 | $2,596.26 | $5,025.85 |