- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,746.54 / $3,033.64 / $3,942.61
| Professional | | $2,746.54 | $3,033.64 | $3,942.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $533.83 / $533.83 / $533.83
| Facility | | $533.83 | $533.83 | $533.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $395.24 / $395.24 / $395.24
| Professional | | $395.24 | $395.24 | $395.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,655.97 / $3,655.97 / $3,655.97
| Facility | | $3,655.97 | $3,655.97 | $3,655.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $408.57 / $3,655.97 / $3,655.97
| Professional | | $408.57 | $3,655.97 | $3,655.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,252.45 / $1,601.16 / $3,544.32
| Professional | | $1,252.45 | $1,601.16 | $3,544.32 |