- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,091.83 / $4,979.14 / $4,979.14
| Professional | | $1,091.83 | $4,979.14 | $4,979.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,496.43 / $1,496.43 / $1,496.43
| Facility | | $1,496.43 | $1,496.43 | $1,496.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,296.60 / $1,496.43 / $1,496.43
| Professional | | $1,296.60 | $1,496.43 | $1,496.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,496.43 / $1,496.43 / $1,496.43
| Facility | | $1,496.43 | $1,496.43 | $1,496.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $927.80 / $1,314.40 / $2,007.60
| Professional | | $927.80 | $1,314.40 | $2,007.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,480.44 / $1,708.20 / $2,635.33
| Professional | | $1,480.44 | $1,708.20 | $2,635.33 |