- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,067.07 / $1,088.76 / $1,088.76
| Professional | | $1,067.07 | $1,088.76 | $1,088.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,286.63 / $1,286.63 / $1,286.63
| Facility | | $1,286.63 | $1,286.63 | $1,286.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,093.64 / $1,157.97 / $1,286.63
| Professional | | $1,093.64 | $1,157.97 | $1,286.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $560.61 / $560.61 / $1,286.63
| Facility | | $560.61 | $560.61 | $1,286.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,093.64 / $1,286.63 / $2,200.17
| Professional | | $1,093.64 | $1,286.63 | $2,200.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.69 / $809.48 / $1,777.27
| Professional | | $175.69 | $809.48 | $1,777.27 |