- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,256.93 / $1,256.93 / $1,450.31
| Professional | | $1,256.93 | $1,256.93 | $1,450.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,207.09 / $1,207.09 / $1,893.13
| Facility | | $1,207.09 | $1,207.09 | $1,893.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $881.18 / $1,207.09 / $1,243.31
| Professional | | $881.18 | $1,207.09 | $1,243.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,207.09 / $1,207.09 / $1,893.13
| Facility | | $1,207.09 | $1,207.09 | $1,893.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $881.18 / $1,207.09 / $1,243.31
| Professional | | $881.18 | $1,207.09 | $1,243.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $875.08 / $1,525.78 / $2,977.68
| Professional | | $875.08 | $1,525.78 | $2,977.68 |