- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,440.41 / $1,440.41 / $1,662.02
| Professional | | $1,440.41 | $1,440.41 | $1,662.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,769.18 / $1,769.18 / $2,169.48
| Facility | | $1,769.18 | $1,769.18 | $2,169.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.50 / $1,769.17 / $1,886.03
| Professional | | $1,291.50 | $1,769.17 | $1,886.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,769.18 / $1,769.18 / $2,169.48
| Facility | | $1,769.18 | $1,769.18 | $2,169.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,291.50 / $1,769.17 / $1,886.03
| Professional | | $1,291.50 | $1,769.17 | $1,886.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $981.72 / $2,128.23 / $3,412.34
| Professional | | $981.72 | $2,128.23 | $3,412.34 |