- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,698.24 / $2,089.30
| Professional | | $1,659.59 | $1,698.24 | $2,089.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $26,302.68
| Facility | | $1,071.52 | $1,071.52 | $26,302.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,412.54 / $6,165.95
| Professional | | $1,071.52 | $1,412.54 | $6,165.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Professional | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,412.54
| Professional | | $1,412.54 | $1,412.54 | $1,412.54 |