- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,698.24 / $2,398.83
| Professional | | $1,122.02 | $1,698.24 | $2,398.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,621.81 / $1,621.81 / $1,621.81
| Facility | | $1,621.81 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,621.81 / $1,621.81
| Professional | | $1,380.38 | $1,621.81 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $131.83 / $977.24 / $1,479.11
| Facility | | $131.83 | $977.24 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.58 / $1,202.26 / $1,995.26
| Professional | | $758.58 | $1,202.26 | $1,995.26 |