- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,324.07 / $3,755.49 / $4,771.64
| Professional | | $3,324.07 | $3,755.49 | $4,771.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $923.03 / $923.03 / $923.03
| Facility | | $923.03 | $923.03 | $923.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $561.65 / $561.65 / $561.65
| Professional | | $561.65 | $561.65 | $561.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,187.00 / $2,187.00 / $3,991.83
| Facility | | $2,187.00 | $2,187.00 | $3,991.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $418.04 / $2,187.00 / $2,187.00
| Professional | | $418.04 | $2,187.00 | $2,187.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,244.58 / $2,178.03 / $4,777.03
| Professional | | $1,244.58 | $2,178.03 | $4,777.03 |