- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,160.55 / $1,160.55 / $1,339.10
| Professional | | $1,160.55 | $1,160.55 | $1,339.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,395.53 / $1,395.53 / $1,747.97
| Facility | | $1,395.53 | $1,395.53 | $1,747.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.74 / $1,018.74 / $1,110.82
| Professional | | $1,018.74 | $1,018.74 | $1,110.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,395.53 / $1,395.53 / $1,747.97
| Facility | | $1,395.53 | $1,395.53 | $1,747.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,018.74 / $1,018.74 / $1,110.82
| Professional | | $1,018.74 | $1,018.74 | $1,110.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $822.62 / $1,915.75 / $1,977.45
| Professional | | $822.62 | $1,915.75 | $1,977.45 |