- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,066.83 / $1,066.83 / $1,230.95
| Professional | | $1,066.83 | $1,066.83 | $1,230.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,212.63 / $1,212.63 / $1,606.80
| Facility | | $1,212.63 | $1,212.63 | $1,606.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $885.22 / $1,212.63 / $1,249.01
| Professional | | $885.22 | $1,212.63 | $1,249.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,212.63 / $1,212.63 / $1,606.80
| Facility | | $1,212.63 | $1,212.63 | $1,606.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $885.22 / $1,212.63 / $1,249.01
| Professional | | $885.22 | $1,212.63 | $1,249.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $779.33 / $1,642.91 / $2,527.30
| Professional | | $779.33 | $1,642.91 | $2,527.30 |