- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,214.51 / $3,673.65 / $4,614.38
| Professional | | $3,214.51 | $3,673.65 | $4,614.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $730.55 / $730.55 / $730.55
| Facility | | $730.55 | $730.55 | $730.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $459.15 / $459.15 / $459.15
| Professional | | $459.15 | $459.15 | $459.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,642.21 / $1,642.21 / $5,792.58
| Facility | | $1,642.21 | $1,642.21 | $5,792.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $470.42 / $1,642.21 / $1,642.21
| Professional | | $470.42 | $1,642.21 | $1,642.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,959.28 / $2,737.81 / $5,671.37
| Professional | | $1,959.28 | $2,737.81 | $5,671.37 |