- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,441.81 / $3,848.63 / $4,940.66
| Professional | | $3,441.81 | $3,848.63 | $4,940.66 |
- 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
- $559.64 / $559.64 / $559.64
| Professional | | $559.64 | $559.64 | $559.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,982.34 / $4,124.25 / $4,133.35
| Facility | | $2,982.34 | $4,124.25 | $4,133.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $441.07 / $4,124.25 / $4,124.25
| Professional | | $441.07 | $4,124.25 | $4,124.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,399.44 / $2,609.55 / $4,777.03
| Professional | | $1,399.44 | $2,609.55 | $4,777.03 |