- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,653.97 / $5,736.71 / $5,736.71
| Professional | | $1,653.97 | $5,736.71 | $5,736.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,317.79 / $2,162.44 / $2,162.44
| Facility | | $1,317.79 | $2,162.44 | $2,162.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,317.79 / $1,758.53 / $2,162.44
| Professional | | $1,317.79 | $1,758.53 | $2,162.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,014.58 / $2,059.48 / $2,162.44
| Facility | | $1,014.58 | $2,059.48 | $2,162.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,317.79 / $1,623.02 / $2,164.02
| Professional | | $1,317.79 | $1,623.02 | $2,164.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $820.56 / $907.89 / $1,399.02
| Professional | | $820.56 | $907.89 | $1,399.02 |