- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,112.84 / $2,485.50 / $2,746.80
| Professional | | $2,112.84 | $2,485.50 | $2,746.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $271.86 / $271.86 / $627.38
| Facility | | $271.86 | $271.86 | $627.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.86 / $292.77 / $376.43
| Professional | | $271.86 | $292.77 | $376.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,569.13 / $2,569.13 / $2,569.13
| Facility | | $2,569.13 | $2,569.13 | $2,569.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.60 / $2,183.76 / $2,569.13
| Professional | | $295.60 | $2,183.76 | $2,569.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.99 / $225.08 / $334.38
| Professional | | $163.99 | $225.08 | $334.38 |