- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,256.60 / $1,256.60 / $1,449.94
| Professional | | $1,256.60 | $1,256.60 | $1,449.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,206.80 / $1,206.80 / $1,892.65
| Facility | | $1,206.80 | $1,206.80 | $1,892.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.96 / $1,206.80 / $1,243.00
| Professional | | $880.96 | $1,206.80 | $1,243.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,206.80 / $1,206.80 / $1,892.65
| Facility | | $1,206.80 | $1,206.80 | $1,892.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $880.96 / $1,206.80 / $1,243.00
| Professional | | $880.96 | $1,206.80 | $1,243.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $874.85 / $1,525.39 / $2,976.91
| Professional | | $874.85 | $1,525.39 | $2,976.91 |