- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,278.42 / $4,434.10 / $4,434.10
| Professional | | $1,278.42 | $4,434.10 | $4,434.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $812.21 / $1,613.67 / $1,613.67
| Facility | | $812.21 | $1,613.67 | $1,613.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.21 / $1,312.25 / $1,613.67
| Professional | | $812.21 | $1,312.25 | $1,613.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $642.62 / $1,536.83 / $1,613.67
| Facility | | $642.62 | $1,536.83 | $1,613.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.21 / $1,211.13 / $1,614.84
| Professional | | $812.21 | $1,211.13 | $1,614.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $519.72 / $575.03 / $886.10
| Professional | | $519.72 | $575.03 | $886.10 |