- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,107.49 / $4,986.27 / $4,986.27
| Professional | | $1,107.49 | $4,986.27 | $4,986.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,524.29 / $1,524.29 / $1,524.29
| Facility | | $1,524.29 | $1,524.29 | $1,524.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,251.56 / $1,524.29 / $1,524.29
| Professional | | $1,251.56 | $1,524.29 | $1,524.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,524.29 / $1,932.45 / $2,018.31
| Facility | | $1,524.29 | $1,932.45 | $2,018.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $937.50 / $1,328.15 / $2,028.60
| Professional | | $937.50 | $1,328.15 | $2,028.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,491.36 / $1,720.80 / $2,668.63
| Professional | | $1,491.36 | $1,720.80 | $2,668.63 |