- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,297.02 / $4,498.64 / $4,498.64
| Professional | | $1,297.02 | $4,498.64 | $4,498.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.71 / $1,695.72 / $1,695.72
| Facility | | $891.71 | $1,695.72 | $1,695.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.71 / $1,695.72 / $1,695.72
| Professional | | $891.71 | $1,695.72 | $1,695.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.71 / $1,614.97 / $1,695.72
| Facility | | $891.71 | $1,614.97 | $1,695.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.71 / $1,272.71 / $1,696.94
| Professional | | $891.71 | $1,272.71 | $1,696.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $643.46 / $711.94 / $1,097.08
| Professional | | $643.46 | $711.94 | $1,097.08 |