- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,128.09 / $3,574.95 / $4,490.32
| Professional | | $3,128.09 | $3,574.95 | $4,490.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $717.84 / $717.84 / $717.84
| Facility | | $717.84 | $717.84 | $717.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $454.49 / $454.49 / $454.49
| Professional | | $454.49 | $454.49 | $454.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,282.89 / $3,282.89 / $5,636.78
| Facility | | $3,282.89 | $3,282.89 | $5,636.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $456.28 / $3,282.89 / $3,282.89
| Professional | | $456.28 | $3,282.89 | $3,282.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,906.64 / $2,859.96 / $5,750.35
| Professional | | $1,906.64 | $2,859.96 | $5,750.35 |