- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,060.38 / $3,499.80 / $4,393.13
| Professional | | $3,060.38 | $3,499.80 | $4,393.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $825.73 / $825.73 / $825.73
| Facility | | $825.73 | $825.73 | $825.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $498.85 / $498.85 / $498.85
| Professional | | $498.85 | $498.85 | $498.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,658.56 / $3,657.49 / $3,675.31
| Facility | | $2,658.56 | $3,657.49 | $3,675.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $390.93 / $3,657.49 / $3,657.49
| Professional | | $390.93 | $3,657.49 | $3,657.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,244.36 / $2,406.44 / $4,666.39
| Professional | | $1,244.36 | $2,406.44 | $4,666.39 |