- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.83 / $1,165.83 / $1,345.19
| Professional | | $1,165.83 | $1,165.83 | $1,345.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,366.32 / $1,366.32 / $1,366.32
| Facility | | $1,366.32 | $1,366.32 | $1,366.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $997.41 / $997.41 / $1,407.31
| Professional | | $997.41 | $997.41 | $1,407.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,366.32 / $1,366.32 / $1,366.32
| Facility | | $1,366.32 | $1,366.32 | $1,366.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $997.41 / $1,366.32 / $1,407.31
| Professional | | $997.41 | $1,366.32 | $1,407.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.58 / $1,643.61 / $2,761.85
| Professional | | $794.58 | $1,643.61 | $2,761.85 |