- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,417.27 / $1,417.27 / $5,557.27
| Professional | | $1,417.27 | $1,417.27 | $5,557.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,217.05 / $1,217.05 / $1,629.32
| Facility | | $1,217.05 | $1,217.05 | $1,629.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,034.49 / $1,217.05 / $2,685.94
| Professional | | $1,034.49 | $1,217.05 | $2,685.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $60.00
| Professional | | $60.00 | $60.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $797.22 / $961.01 / $1,771.59
| Professional | | $797.22 | $961.01 | $1,771.59 |