- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,621.81
| Professional | | $1,380.38 | $1,380.38 | $1,621.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,819.70 / $1,819.70
| Facility | | $1,380.38 | $1,819.70 | $1,819.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,737.80 / $1,949.84
| Professional | | $1,380.38 | $1,737.80 | $1,949.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.97 / $1,445.44 / $2,630.27
| Facility | | $181.97 | $1,445.44 | $2,630.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $125.89 / $2,454.71
| Professional | | $79.43 | $125.89 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $165.96 / $1,949.84
| Professional | | $125.89 | $165.96 | $1,949.84 |