- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $933.25 / $1,584.89 / $2,570.40
| Professional | | $933.25 | $1,584.89 | $2,570.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,949.84 / $1,949.84 / $1,949.84
| Facility | | $1,949.84 | $1,949.84 | $1,949.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,659.59 / $1,949.84 / $1,995.26
| Professional | | $1,659.59 | $1,949.84 | $1,995.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.97 / $1,096.48 / $1,659.59
| Facility | | $181.97 | $1,096.48 | $1,659.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $851.14 / $2,089.30 / $2,570.40
| Professional | | $851.14 | $2,089.30 | $2,570.40 |