- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,215.47 / $1,215.47 / $1,402.46
| Professional | | $1,215.47 | $1,215.47 | $1,402.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,747.16 / $1,747.16 / $1,830.69
| Facility | | $1,747.16 | $1,747.16 | $1,830.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.43 / $1,614.08 / $1,799.57
| Professional | | $1,275.43 | $1,614.08 | $1,799.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,747.16 / $1,747.16 / $1,830.69
| Facility | | $1,747.16 | $1,747.16 | $1,830.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,275.43 / $1,747.16 / $1,799.57
| Professional | | $1,275.43 | $1,747.16 | $1,799.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $861.55 / $1,475.45 / $2,879.44
| Professional | | $861.55 | $1,475.45 | $2,879.44 |