- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,215.49 / $1,215.49 / $1,402.49
| Professional | | $1,215.49 | $1,215.49 | $1,402.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,167.30 / $1,167.30 / $1,830.72
| Facility | | $1,167.30 | $1,167.30 | $1,830.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $852.13 / $1,167.30 / $1,244.40
| Professional | | $852.13 | $1,167.30 | $1,244.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,167.30 / $1,167.30 / $1,830.72
| Facility | | $1,167.30 | $1,167.30 | $1,830.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $852.13 / $1,167.30 / $1,244.40
| Professional | | $852.13 | $1,167.30 | $1,244.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $861.56 / $1,475.47 / $2,879.50
| Professional | | $861.56 | $1,475.47 | $2,879.50 |