- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,220.91 / $1,220.91 / $1,408.75
| Professional | | $1,220.91 | $1,220.91 | $1,408.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,172.51 / $1,172.51 / $1,838.89
| Facility | | $1,172.51 | $1,172.51 | $1,838.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $855.93 / $1,172.51 / $1,207.69
| Professional | | $855.93 | $1,172.51 | $1,207.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,172.51 / $1,172.51 / $1,838.89
| Facility | | $1,172.51 | $1,172.51 | $1,838.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $855.93 / $1,172.51 / $1,207.69
| Professional | | $855.93 | $1,172.51 | $1,207.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $850.01 / $1,880.21 / $2,892.35
| Professional | | $850.01 | $1,880.21 | $2,892.35 |