- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,396.11 / $2,485.96 / $2,545.87
| Professional | | $2,396.11 | $2,485.96 | $2,545.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $348.08 / $348.08 / $764.48
| Facility | | $348.08 | $348.08 | $764.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $348.08 / $2,545.87 / $2,545.87
| Professional | | $348.08 | $2,545.87 | $2,545.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $295.67 / $381.50 / $2,995.14
| Facility | | $295.67 | $381.50 | $2,995.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $348.08 / $2,545.87 / $3,119.94
| Professional | | $348.08 | $2,545.87 | $3,119.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,495.94 / $2,495.94 / $2,495.94
| Professional | | $2,495.94 | $2,495.94 | $2,495.94 |