- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,116.71 / $1,116.71 / $1,288.52
| Professional | | $1,116.71 | $1,116.71 | $1,288.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,665.63 / $1,665.63 / $1,681.94
| Facility | | $1,665.63 | $1,665.63 | $1,681.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,215.91 / $1,665.63 / $1,715.60
| Professional | | $1,215.91 | $1,665.63 | $1,715.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,665.63 / $1,665.63 / $1,681.94
| Facility | | $1,665.63 | $1,665.63 | $1,681.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,215.91 / $1,665.63 / $1,715.60
| Professional | | $1,215.91 | $1,665.63 | $1,715.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $761.10 / $1,719.74 / $2,645.49
| Professional | | $761.10 | $1,719.74 | $2,645.49 |