- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,328.61 / $1,779.38 / $1,779.38
| Professional | | $1,328.61 | $1,779.38 | $1,779.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,786.79 / $1,786.79 / $1,786.79
| Facility | | $1,786.79 | $1,786.79 | $1,786.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,518.77 / $1,786.79 / $1,840.39
| Professional | | $1,518.77 | $1,786.79 | $1,840.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,786.79 / $1,786.79 / $1,786.79
| Facility | | $1,786.79 | $1,786.79 | $1,786.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,786.79 / $1,786.79 / $1,840.39
| Professional | | $1,786.79 | $1,786.79 | $1,840.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,051.05 / $1,700.30 / $2,627.63
| Professional | | $1,051.05 | $1,700.30 | $2,627.63 |