- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,208.63 / $2,722.23 / $3,170.45
| Professional | | $2,208.63 | $2,722.23 | $3,170.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $429.26 / $429.26 / $429.26
| Facility | | $429.26 | $429.26 | $429.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $317.83 / $317.83 / $317.83
| Professional | | $317.83 | $317.83 | $317.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,225.05 / $2,225.05 / $2,225.05
| Facility | | $2,225.05 | $2,225.05 | $2,225.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.68 / $2,225.05 / $2,225.05
| Professional | | $343.68 | $2,225.05 | $2,225.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $955.36 / $1,594.94 / $3,332.35
| Professional | | $955.36 | $1,594.94 | $3,332.35 |