- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,021.82 / $3,412.21 / $4,652.56
| Professional | | $3,021.82 | $3,412.21 | $4,652.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $845.03 / $845.03 / $845.03
| Facility | | $845.03 | $845.03 | $845.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $516.62 / $516.62 / $516.62
| Professional | | $516.62 | $516.62 | $516.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,673.00 / $2,673.00 / $3,628.77
| Facility | | $2,673.00 | $2,673.00 | $3,628.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $378.53 / $2,673.00 / $3,214.80
| Professional | | $378.53 | $2,673.00 | $3,214.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,188.83 / $2,080.44 / $4,607.89
| Professional | | $1,188.83 | $2,080.44 | $4,607.89 |