- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,388.67 / $2,388.67 / $2,388.67
| Professional | | $2,388.67 | $2,388.67 | $2,388.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.76 / $287.76 / $3,120.84
| Professional | | $287.76 | $287.76 | $3,120.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $207.66 / $346.09 / $2,949.27
| Facility | | $207.66 | $346.09 | $2,949.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.76 / $405.58 / $3,120.84
| Professional | | $287.76 | $405.58 | $3,120.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,370.35 / $1,713.46 / $1,796.18
| Professional | | $1,370.35 | $1,713.46 | $1,796.18 |