- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,961.76 / $3,035.87 / $3,551.76
| Professional | | $1,961.76 | $3,035.87 | $3,551.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $160.94 / $160.94 / $160.94
| Facility | | $160.94 | $160.94 | $160.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,255.90 / $3,255.90 / $3,255.90
| Professional | | $3,255.90 | $3,255.90 | $3,255.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,446.40 / $2,446.40 / $3,210.83
| Facility | | $2,446.40 | $2,446.40 | $3,210.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.94 / $2,446.40 / $4,372.50
| Professional | | $286.94 | $2,446.40 | $4,372.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $957.17 / $1,675.05 / $3,290.25
| Professional | | $957.17 | $1,675.05 | $3,290.25 |