- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,144.84 / $5,153.06 / $5,153.06
| Professional | | $1,144.84 | $5,153.06 | $5,153.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,574.25 / $1,574.25 / $1,574.25
| Facility | | $1,574.25 | $1,574.25 | $1,574.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,284.38 / $1,574.25 / $1,574.25
| Professional | | $1,284.38 | $1,574.25 | $1,574.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,574.25 / $2,029.30 / $2,112.55
| Facility | | $1,574.25 | $2,029.30 | $2,112.55 |
- 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
- $1,542.84 / $1,780.20 / $2,757.43
| Professional | | $1,542.84 | $1,780.20 | $2,757.43 |