- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.00 / $4,852.66 / $4,852.66
| Professional | | $1,165.00 | $4,852.66 | $4,852.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,450.68 / $1,450.68 / $1,450.68
| Facility | | $1,450.68 | $1,450.68 | $1,450.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,052.94 / $1,450.68 / $1,548.12
| Professional | | $1,052.94 | $1,450.68 | $1,548.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $717.72 / $1,723.80 / $1,767.84
| Facility | | $717.72 | $1,723.80 | $1,767.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $874.74 / $1,312.25 / $1,892.80
| Professional | | $874.74 | $1,312.25 | $1,892.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,352.52 / $1,597.81 / $2,521.56
| Professional | | $1,352.52 | $1,597.81 | $2,521.56 |