- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,043.61 / $1,043.61 / $1,204.18
| Professional | | $1,043.61 | $1,043.61 | $1,204.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,408.48 / $1,408.48 / $1,571.86
| Facility | | $1,408.48 | $1,408.48 | $1,571.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.19 / $1,282.71 / $1,450.73
| Professional | | $1,028.19 | $1,282.71 | $1,450.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,408.48 / $1,408.48 / $1,571.86
| Facility | | $1,408.48 | $1,408.48 | $1,571.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,028.19 / $1,408.48 / $1,450.73
| Professional | | $1,028.19 | $1,408.48 | $1,450.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $739.73 / $1,266.84 / $2,472.34
| Professional | | $739.73 | $1,266.84 | $2,472.34 |