- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,524.14 / $5,286.41 / $5,286.41
| Professional | | $1,524.14 | $5,286.41 | $5,286.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,036.33 / $1,448.44 / $1,448.44
| Facility | | $1,036.33 | $1,448.44 | $1,448.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,036.33 / $1,177.89 / $1,448.44
| Professional | | $1,036.33 | $1,177.89 | $1,448.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $766.13 / $1,379.47 / $1,448.44
| Facility | | $766.13 | $1,379.47 | $1,448.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,036.33 / $1,087.11 / $1,449.49
| Professional | | $1,036.33 | $1,087.11 | $1,449.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $619.61 / $685.56 / $1,087.29
| Professional | | $619.61 | $685.56 | $1,087.29 |