- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,143.92 / $5,153.75 / $5,153.75
| Professional | | $1,143.92 | $5,153.75 | $5,153.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,575.82 / $1,575.82 / $1,575.82
| Facility | | $1,575.82 | $1,575.82 | $1,575.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,300.64 / $1,575.82 / $1,575.82
| Professional | | $1,300.64 | $1,575.82 | $1,575.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,575.82 / $2,046.20 / $2,168.21
| Facility | | $1,575.82 | $2,046.20 | $2,168.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $968.56 / $1,372.15 / $2,095.80
| Professional | | $968.56 | $1,372.15 | $2,095.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,541.29 / $1,851.28 / $2,758.36
| Professional | | $1,541.29 | $1,851.28 | $2,758.36 |