- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,232.60 / $1,232.60 / $1,422.25
| Professional | | $1,232.60 | $1,232.60 | $1,422.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,424.68 / $1,424.68 / $1,856.51
| Facility | | $1,424.68 | $1,424.68 | $1,856.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.02 / $1,040.02 / $1,419.76
| Professional | | $1,040.02 | $1,040.02 | $1,419.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,424.68 / $1,424.68 / $1,856.51
| Facility | | $1,424.68 | $1,424.68 | $1,856.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,040.02 / $1,040.02 / $1,419.76
| Professional | | $1,040.02 | $1,040.02 | $1,419.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $840.09 / $1,713.81 / $2,920.07
| Professional | | $840.09 | $1,713.81 | $2,920.07 |