- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,184.28 / $1,278.08 / $1,360.17
| Professional | | $1,184.28 | $1,278.08 | $1,360.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,361.25 / $1,361.25 / $1,361.25
| Facility | | $1,361.25 | $1,361.25 | $1,361.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,361.25 / $1,361.25
| Professional | | $1,172.56 | $1,361.25 | $1,361.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,207.73 / $1,361.25
| Facility | | $1,172.56 | $1,207.73 | $1,361.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,246.56 / $1,272.11 / $1,659.28
| Professional | | $1,246.56 | $1,272.11 | $1,659.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,172.56 / $1,172.56 / $1,172.56
| Professional | | $1,172.56 | $1,172.56 | $1,172.56 |