- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,624.74 / $5,635.31 / $5,635.31
| Professional | | $1,624.74 | $5,635.31 | $5,635.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,316.65 / $1,994.57 / $1,994.57
| Facility | | $1,316.65 | $1,994.57 | $1,994.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,316.65 / $1,622.01 / $1,994.57
| Professional | | $1,316.65 | $1,622.01 | $1,994.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $990.81 / $1,899.59 / $1,994.57
| Facility | | $990.81 | $1,899.59 | $1,994.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,316.65 / $1,497.02 / $1,996.02
| Professional | | $1,316.65 | $1,497.02 | $1,996.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $801.33 / $886.60 / $1,406.15
| Professional | | $801.33 | $886.60 | $1,406.15 |