- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,659.59
| Professional | | $1,412.54 | $1,412.54 | $1,659.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,584.89 / $1,584.89
| Facility | | $1,412.54 | $1,584.89 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,584.89 / $2,041.74
| Professional | | $1,412.54 | $1,584.89 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.78 / $1,445.44 / $2,398.83
| Facility | | $173.78 | $1,445.44 | $2,398.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $1,584.89 / $2,454.71
| Professional | | $125.89 | $1,584.89 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $165.96 / $1,445.44
| Professional | | $125.89 | $165.96 | $1,445.44 |