- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,074.10 / $1,074.10 / $1,239.35
| Professional | | $1,074.10 | $1,074.10 | $1,239.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,179.41 / $1,179.41 / $1,617.77
| Facility | | $1,179.41 | $1,179.41 | $1,617.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.97 / $1,179.40 / $1,214.79
| Professional | | $860.97 | $1,179.40 | $1,214.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,179.41 / $1,179.41 / $1,617.77
| Facility | | $1,179.41 | $1,179.41 | $1,617.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $860.97 / $1,179.40 / $1,214.79
| Professional | | $860.97 | $1,179.40 | $1,214.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $761.35 / $1,303.84 / $2,544.56
| Professional | | $761.35 | $1,303.84 | $2,544.56 |