- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,068.10 / $1,068.10 / $1,232.43
| Professional | | $1,068.10 | $1,068.10 | $1,232.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,375.24 / $1,375.24 / $1,608.73
| Facility | | $1,375.24 | $1,375.24 | $1,608.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,003.93 / $1,375.24 / $1,416.50
| Professional | | $1,003.93 | $1,375.24 | $1,416.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,375.24 / $1,375.24 / $1,608.73
| Facility | | $1,375.24 | $1,375.24 | $1,608.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,003.93 / $1,375.24 / $1,416.50
| Professional | | $1,003.93 | $1,375.24 | $1,416.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $727.97 / $1,313.47 / $2,530.34
| Professional | | $727.97 | $1,313.47 | $2,530.34 |