- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,354.80 / $2,425.44 / $3,701.39
| Professional | | $2,354.80 | $2,425.44 | $3,701.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $445.20 / $869.55 / $1,005.48
| Facility | | $445.20 | $869.55 | $1,005.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $378.42 / $445.20 / $445.20
| Professional | | $378.42 | $445.20 | $445.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,360.51 / $3,360.51 / $3,360.51
| Facility | | $3,360.51 | $3,360.51 | $3,360.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,472.88 / $1,472.88 / $1,472.88
| Professional | | $1,472.88 | $1,472.88 | $1,472.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.05 / $394.56 / $2,987.85
| Professional | | $271.05 | $394.56 | $2,987.85 |