- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,212.72 / $4,206.26 / $4,206.26
| Professional | | $1,212.72 | $4,206.26 | $4,206.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $719.79 / $1,530.74 / $1,530.74
| Facility | | $719.79 | $1,530.74 | $1,530.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $719.79 / $1,244.81 / $1,530.74
| Professional | | $719.79 | $1,244.81 | $1,530.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $609.58 / $1,457.85 / $1,530.74
| Facility | | $609.58 | $1,457.85 | $1,530.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $719.79 / $1,148.90 / $1,531.86
| Professional | | $719.79 | $1,148.90 | $1,531.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $493.01 / $545.48 / $865.13
| Professional | | $493.01 | $545.48 | $865.13 |