- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,023.50 / $7,018.39 / $7,018.39
| Professional | | $2,023.50 | $7,018.39 | $7,018.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,573.58 / $2,154.40 / $2,154.40
| Facility | | $1,573.58 | $2,154.40 | $2,154.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,573.58 / $1,751.98 / $2,154.40
| Professional | | $1,573.58 | $1,751.98 | $2,154.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,017.14 / $2,051.81 / $2,154.40
| Facility | | $1,017.14 | $2,051.81 | $2,154.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,573.58 / $1,616.97 / $2,155.96
| Professional | | $1,573.58 | $1,616.97 | $2,155.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $822.62 / $910.17 / $1,402.54
| Professional | | $822.62 | $910.17 | $1,402.54 |