- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,320.62 / $1,320.62 / $1,523.80
| Professional | | $1,320.62 | $1,320.62 | $1,523.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,606.19 / $1,606.19 / $1,989.06
| Facility | | $1,606.19 | $1,606.19 | $1,989.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.52 / $1,606.19 / $1,654.38
| Professional | | $1,172.52 | $1,606.19 | $1,654.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,606.19 / $1,606.19 / $1,989.06
| Facility | | $1,606.19 | $1,606.19 | $1,989.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.52 / $1,606.19 / $1,654.38
| Professional | | $1,172.52 | $1,606.19 | $1,654.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,041.63 / $2,250.19 / $2,250.19
| Professional | | $1,041.63 | $2,250.19 | $2,250.19 |