- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,835.20 / $6,365.30 / $6,365.30
| Professional | | $1,835.20 | $6,365.30 | $6,365.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,427.14 / $1,766.16 / $1,766.16
| Facility | | $1,427.14 | $1,766.16 | $1,766.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,427.14 / $1,469.95 / $1,766.16
| Professional | | $1,427.14 | $1,469.95 | $1,766.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $922.49 / $1,682.06 / $1,766.16
| Facility | | $922.49 | $1,682.06 | $1,766.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,325.58 / $1,427.14 / $1,931.79
| Professional | | $1,325.58 | $1,427.14 | $1,931.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $746.08 / $825.47 / $1,272.03
| Professional | | $746.08 | $825.47 | $1,272.03 |