- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,226.54 / $2,544.53 / $3,196.17
| Professional | | $2,226.54 | $2,544.53 | $3,196.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $504.49 / $504.49 / $504.49
| Facility | | $504.49 | $504.49 | $504.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.35 / $318.35 / $318.35
| Professional | | $318.35 | $318.35 | $318.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,399.94 / $2,399.94 / $4,012.16
| Facility | | $2,399.94 | $2,399.94 | $4,012.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.16 / $2,399.94 / $2,399.94
| Professional | | $326.16 | $2,399.94 | $2,399.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,357.08 / $1,890.71 / $3,916.58
| Professional | | $1,357.08 | $1,890.71 | $3,916.58 |