- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $299.47 / $1,669.10 / $5,398.72
| Professional | | $299.47 | $1,669.10 | $5,398.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $496.88 / $496.88 / $496.88
| Facility | | $496.88 | $496.88 | $496.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $496.88 / $546.50 / $1,726.79
| Professional | | $496.88 | $546.50 | $1,726.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $311.80 / $2,134.60 / $2,249.80
| Facility | | $311.80 | $2,134.60 | $2,249.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.51 / $839.71 / $1,726.79
| Professional | | $323.51 | $839.71 | $1,726.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,480.44 / $1,708.20 / $2,440.13
| Professional | | $1,480.44 | $1,708.20 | $2,440.13 |