- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,076.40 / $6,018.48 / $6,018.48
| Professional | | $1,076.40 | $6,018.48 | $6,018.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,357.20 / $1,825.20 / $2,765.88
| Facility | | $1,357.20 | $1,825.20 | $2,765.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,075.86 / $1,357.20 / $1,357.20
| Professional | | $1,075.86 | $1,357.20 | $1,357.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,357.20 / $1,825.20 / $2,765.88
| Facility | | $1,357.20 | $1,825.20 | $2,765.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $842.40 / $842.40 / $1,357.20
| Professional | | $842.40 | $842.40 | $1,357.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $393.12 / $393.12 / $936.00
| Professional | | $393.12 | $393.12 | $936.00 |