- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,170.22 / $5,270.88 / $5,270.88
| Professional | | $1,170.22 | $5,270.88 | $5,270.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,613.15 / $1,613.15 / $1,613.15
| Facility | | $1,613.15 | $1,613.15 | $1,613.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,101.95 / $1,613.15 / $1,613.15
| Professional | | $1,101.95 | $1,613.15 | $1,613.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,613.15 / $1,738.75 / $1,781.12
| Facility | | $1,613.15 | $1,738.75 | $1,781.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $990.88 / $1,403.77 / $2,144.10
| Professional | | $990.88 | $1,403.77 | $2,144.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,424.09 / $1,787.69 / $2,823.10
| Professional | | $1,424.09 | $1,787.69 | $2,823.10 |