- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,622.91 / $4,011.15 / $5,200.63
| Professional | | $3,622.91 | $4,011.15 | $5,200.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $991.07 / $991.07 / $991.07
| Facility | | $991.07 | $991.07 | $991.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $593.87 / $593.87 / $593.87
| Professional | | $593.87 | $593.87 | $593.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,165.54 / $4,303.28 / $4,350.72
| Facility | | $3,165.54 | $4,303.28 | $4,350.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $459.38 / $4,303.28 / $4,303.28
| Professional | | $459.38 | $4,303.28 | $4,303.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,473.15 / $2,578.01 / $5,129.10
| Professional | | $1,473.15 | $2,578.01 | $5,129.10 |