- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,646.10 / $1,907.40 / $2,057.63
| Professional | | $1,646.10 | $1,907.40 | $2,057.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.48 / $310.66 / $2,407.42
| Facility | | $204.48 | $310.66 | $2,407.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.21 / $334.55 / $430.15
| Professional | | $220.21 | $334.55 | $430.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,850.09 / $1,850.09 / $3,497.79
| Facility | | $1,850.09 | $1,850.09 | $3,497.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.23 / $1,850.09 / $14,627.50
| Professional | | $249.23 | $1,850.09 | $14,627.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,555.14 / $1,887.48 / $3,420.77
| Professional | | $1,555.14 | $1,887.48 | $3,420.77 |