- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.21 / $5,120.72 / $5,120.72
| Professional | | $1,122.21 | $5,120.72 | $5,120.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,591.60 / $1,591.60 / $1,591.60
| Facility | | $1,591.60 | $1,591.60 | $1,591.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,041.40 / $1,591.60 / $1,591.60
| Professional | | $1,041.40 | $1,591.60 | $1,591.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $776.13 / $1,591.60 / $1,607.82
| Facility | | $776.13 | $1,591.60 | $1,607.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $978.59 / $1,418.92 / $2,117.50
| Professional | | $978.59 | $1,418.92 | $2,117.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,299.55 / $1,631.35 / $2,813.85
| Professional | | $1,299.55 | $1,631.35 | $2,813.85 |