- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,645.31 / $5,706.66 / $5,706.66
| Professional | | $1,645.31 | $5,706.66 | $5,706.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,260.83 / $1,801.12 / $1,801.12
| Facility | | $1,260.83 | $1,801.12 | $1,801.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.83 / $1,801.12 / $1,801.12
| Professional | | $1,260.83 | $1,801.12 | $1,801.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $860.58 / $1,715.35 / $1,801.12
| Facility | | $860.58 | $1,715.35 | $1,801.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.83 / $1,351.82 / $1,802.42
| Professional | | $1,260.83 | $1,351.82 | $1,802.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $696.01 / $770.08 / $1,186.67
| Professional | | $696.01 | $770.08 | $1,186.67 |