- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,039.67 / $3,476.10 / $4,363.39
| Professional | | $3,039.67 | $3,476.10 | $4,363.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $823.17 / $823.17 / $823.17
| Facility | | $823.17 | $823.17 | $823.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $496.22 / $496.22 / $496.22
| Professional | | $496.22 | $496.22 | $496.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,644.69 / $3,626.76 / $3,650.37
| Facility | | $2,644.69 | $3,626.76 | $3,650.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $387.52 / $3,626.76 / $3,626.76
| Professional | | $387.52 | $3,626.76 | $3,626.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,235.95 / $2,314.11 / $4,260.05
| Professional | | $1,235.95 | $2,314.11 | $4,260.05 |