- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,618.66 / $1,618.66 / $1,618.66
| Professional | | $1,618.66 | $1,618.66 | $1,618.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,184.86 / $2,184.86 / $2,184.86
| Facility | | $2,184.86 | $2,184.86 | $2,184.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,500.02 / $1,500.02 / $1,875.02
| Professional | | $1,500.02 | $1,500.02 | $1,875.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,184.86 / $2,184.86 / $2,184.86
| Facility | | $2,184.86 | $2,184.86 | $2,184.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $848.49 / $1,500.02 / $1,875.02
| Professional | | $848.49 | $1,500.02 | $1,875.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $783.22 / $783.22 / $1,827.52
| Professional | | $783.22 | $783.22 | $1,827.52 |