- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,283.04 / $1,283.04 / $1,480.43
| Professional | | $1,283.04 | $1,283.04 | $1,480.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,482.94 / $1,482.94 / $1,932.47
| Facility | | $1,482.94 | $1,482.94 | $1,932.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.50 / $1,477.89 / $1,527.43
| Professional | | $1,260.50 | $1,477.89 | $1,527.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,482.94 / $1,482.94 / $1,932.47
| Facility | | $1,482.94 | $1,482.94 | $1,932.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,260.50 / $1,482.94 / $1,527.43
| Professional | | $1,260.50 | $1,482.94 | $1,527.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $909.44 / $1,975.89 / $3,039.53
| Professional | | $909.44 | $1,975.89 | $3,039.53 |