- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,536.50 / $1,536.50 / $1,536.50
| Professional | | $1,536.50 | $1,536.50 | $1,536.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,937.33 / $1,937.33 / $1,937.33
| Facility | | $1,937.33 | $1,937.33 | $1,937.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,937.33 / $1,937.33 / $1,937.33
| Professional | | $1,937.33 | $1,937.33 | $1,937.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,937.33 / $1,937.33 / $1,937.33
| Facility | | $1,937.33 | $1,937.33 | $1,937.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.48 / $1,202.48 / $1,937.33
| Professional | | $1,202.48 | $1,202.48 | $1,937.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $561.16 / $561.16 / $1,336.09
| Professional | | $561.16 | $561.16 | $1,336.09 |