- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,043.15 / $1,043.15 / $1,203.63
| Professional | | $1,043.15 | $1,043.15 | $1,203.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,222.54 / $1,222.54 / $1,571.14
| Facility | | $1,222.54 | $1,222.54 | $1,571.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $892.45 / $892.45 / $1,218.45
| Professional | | $892.45 | $892.45 | $1,218.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,222.54 / $1,222.54 / $1,571.14
| Facility | | $1,222.54 | $1,222.54 | $1,571.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $892.45 / $892.45 / $1,218.45
| Professional | | $892.45 | $892.45 | $1,218.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $710.97 / $1,470.66 / $2,471.21
| Professional | | $710.97 | $1,470.66 | $2,471.21 |