- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,112.28 / $1,112.28 / $1,112.28
| Professional | | $1,112.28 | $1,112.28 | $1,112.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,501.35 / $1,501.35 / $1,501.35
| Facility | | $1,501.35 | $1,501.35 | $1,501.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,030.84 / $1,030.84 / $1,288.56
| Professional | | $1,030.84 | $1,030.84 | $1,288.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,501.35 / $1,501.35 / $1,501.35
| Facility | | $1,501.35 | $1,501.35 | $1,501.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $583.04 / $1,030.84 / $1,288.56
| Professional | | $583.04 | $1,030.84 | $1,288.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $538.20 / $538.20 / $1,255.80
| Professional | | $538.20 | $538.20 | $1,255.80 |