- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,849.71 / $2,101.62 / $2,655.23
| Professional | | $1,849.71 | $2,101.62 | $2,655.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $459.82 / $459.82 / $459.82
| Facility | | $459.82 | $459.82 | $459.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $304.74 / $304.74 / $304.74
| Professional | | $304.74 | $304.74 | $304.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,918.38 / $2,225.09 / $2,225.09
| Facility | | $1,918.38 | $2,225.09 | $2,225.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.17 / $2,225.09 / $2,225.09
| Professional | | $246.17 | $2,225.09 | $2,225.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $737.71 / $1,290.99 / $2,379.69
| Professional | | $737.71 | $1,290.99 | $2,379.69 |