- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,675.17 / $2,630.41 / $2,785.14
| Professional | | $1,675.17 | $2,630.41 | $2,785.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.66 / $150.66 / $150.66
| Facility | | $150.66 | $150.66 | $150.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,331.80 / $2,331.80 / $2,331.80
| Professional | | $2,331.80 | $2,331.80 | $2,331.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,387.48 / $2,387.48 / $2,387.48
| Facility | | $2,387.48 | $2,387.48 | $2,387.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.77 / $2,387.48 / $3,993.75
| Professional | | $251.77 | $2,387.48 | $3,993.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $761.81 / $1,170.08 / $2,100.92
| Professional | | $761.81 | $1,170.08 | $2,100.92 |