- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,310.39 / $1,310.39 / $1,511.99
| Professional | | $1,310.39 | $1,310.39 | $1,511.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,544.16 / $1,544.16 / $1,973.64
| Facility | | $1,544.16 | $1,544.16 | $1,973.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.24 / $1,544.16 / $1,590.48
| Professional | | $1,127.24 | $1,544.16 | $1,590.48 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,544.16 / $1,544.16 / $1,973.64
| Facility | | $1,544.16 | $1,544.16 | $1,973.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,127.24 / $1,544.16 / $1,590.48
| Professional | | $1,127.24 | $1,544.16 | $1,590.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $893.10 / $1,590.66 / $3,104.31
| Professional | | $893.10 | $1,590.66 | $3,104.31 |