- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,107.56 / $4,994.68 / $4,994.68
| Professional | | $1,107.56 | $4,994.68 | $4,994.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,526.40 / $1,526.40 / $1,526.40
| Facility | | $1,526.40 | $1,526.40 | $1,526.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,257.63 / $1,526.40 / $1,526.40
| Professional | | $1,257.63 | $1,526.40 | $1,526.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,526.40 / $1,944.80 / $1,996.80
| Facility | | $1,526.40 | $1,944.80 | $1,996.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $938.15 / $1,329.07 / $2,030.00
| Professional | | $938.15 | $1,329.07 | $2,030.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,492.92 / $1,722.60 / $2,675.10
| Professional | | $1,492.92 | $1,722.60 | $2,675.10 |