- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.88 / $1,096.88 / $1,096.88
| Professional | | $1,096.88 | $1,096.88 | $1,096.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,773.52 / $1,773.52 / $1,773.52
| Facility | | $1,773.52 | $1,773.52 | $1,773.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $909.20 / $1,773.52 / $1,850.18
| Professional | | $909.20 | $1,773.52 | $1,850.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $864.09 / $1,029.46 / $2,508.91
| Facility | | $864.09 | $1,029.46 | $2,508.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,074.67 / $1,612.17 / $1,850.18
| Professional | | $1,074.67 | $1,612.17 | $1,850.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,658.22 / $1,882.68 / $2,057.31
| Professional | | $1,658.22 | $1,882.68 | $2,057.31 |