- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,285.82 / $2,648.93 / $2,880.68
| Professional | | $2,285.82 | $2,648.93 | $2,880.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $285.12 / $295.08 / $350.92
| Facility | | $285.12 | $295.08 | $350.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $285.12 / $307.06 / $394.79
| Professional | | $285.12 | $307.06 | $394.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,225.05 / $2,225.05 / $4,290.42
| Facility | | $2,225.05 | $2,225.05 | $4,290.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.68 / $2,225.05 / $17,942.16
| Professional | | $343.68 | $2,225.05 | $17,942.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,458.88 / $1,754.60 / $3,259.24
| Professional | | $1,458.88 | $1,754.60 | $3,259.24 |