- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,332.32 / $1,332.32 / $1,537.29
| Professional | | $1,332.32 | $1,332.32 | $1,537.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,549.06 / $1,549.06 / $2,006.69
| Facility | | $1,549.06 | $1,549.06 | $2,006.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,130.81 / $1,549.06 / $1,595.53
| Professional | | $1,130.81 | $1,549.06 | $1,595.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,549.06 / $1,549.06 / $2,006.69
| Facility | | $1,549.06 | $1,549.06 | $2,006.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,130.81 / $1,549.06 / $1,595.53
| Professional | | $1,130.81 | $1,549.06 | $1,595.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $908.04 / $1,617.30 / $3,156.26
| Professional | | $908.04 | $1,617.30 | $3,156.26 |