- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,271.69 / $1,271.69 / $1,467.33
| Professional | | $1,271.69 | $1,271.69 | $1,467.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,271.83 / $1,271.83 / $1,915.36
| Facility | | $1,271.83 | $1,271.83 | $1,915.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.44 / $1,271.83 / $1,309.98
| Professional | | $928.44 | $1,271.83 | $1,309.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,271.83 / $1,271.83 / $1,915.36
| Facility | | $1,271.83 | $1,271.83 | $1,915.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $928.44 / $1,271.83 / $1,309.98
| Professional | | $928.44 | $1,271.83 | $1,309.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $866.72 / $1,543.69 / $3,012.63
| Professional | | $866.72 | $1,543.69 | $3,012.63 |