- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,151.61 / $1,151.61 / $1,328.79
| Professional | | $1,151.61 | $1,151.61 | $1,328.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,734.51 / $1,823.10 / $1,823.10
| Facility | | $1,734.51 | $1,823.10 | $1,823.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,330.86 / $1,823.10 / $1,877.79
| Professional | | $1,330.86 | $1,823.10 | $1,877.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,734.51 / $1,823.10 / $1,823.10
| Facility | | $1,734.51 | $1,823.10 | $1,823.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,330.86 / $1,823.10 / $1,877.79
| Professional | | $1,330.86 | $1,823.10 | $1,877.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $784.89 / $1,753.48 / $2,728.18
| Professional | | $784.89 | $1,753.48 | $2,728.18 |