- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,012.62 / $1,390.87 / $2,737.46
| Professional | | $1,012.62 | $1,390.87 | $2,737.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,440.00 / $1,440.00 / $1,468.80
| Facility | | $1,440.00 | $1,440.00 | $1,468.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,224.00 / $1,440.00 / $3,832.50
| Professional | | $1,224.00 | $1,440.00 | $3,832.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,887.62 / $2,887.62 / $2,887.62
| Professional | | $2,887.62 | $2,887.62 | $2,887.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,198.96 / $2,198.96 / $2,198.96
| Professional | | $2,198.96 | $2,198.96 | $2,198.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,391.26 / $1,623.13 / $3,043.92
| Professional | | $1,391.26 | $1,623.13 | $3,043.92 |