- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,083.33 / $3,757.45 / $3,757.45
| Professional | | $1,083.33 | $3,757.45 | $3,757.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $875.29 / $1,265.81 / $1,265.81
| Facility | | $875.29 | $1,265.81 | $1,265.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $875.29 / $1,029.38 / $1,265.81
| Professional | | $875.29 | $1,029.38 | $1,265.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $604.16 / $1,205.53 / $1,265.81
| Facility | | $604.16 | $1,205.53 | $1,265.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $875.29 / $950.05 / $1,266.73
| Professional | | $875.29 | $950.05 | $1,266.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $488.63 / $540.63 / $833.09
| Professional | | $488.63 | $540.63 | $833.09 |