- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,041.53 / $7,080.92 / $7,080.92
| Professional | | $2,041.53 | $7,080.92 | $7,080.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,408.48 / $2,576.90 / $2,576.90
| Facility | | $1,408.48 | $2,576.90 | $2,576.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,408.48 / $2,095.56 / $2,576.90
| Professional | | $1,408.48 | $2,095.56 | $2,576.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,026.20 / $2,454.19 / $2,576.90
| Facility | | $1,026.20 | $2,454.19 | $2,576.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,408.48 / $1,934.08 / $2,578.78
| Professional | | $1,408.48 | $1,934.08 | $2,578.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $829.96 / $918.28 / $1,456.38
| Professional | | $829.96 | $918.28 | $1,456.38 |