- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,592.05 / $1,592.05 / $2,198.54
| Facility | | $1,592.05 | $1,592.05 | $2,198.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $758.12 / $1,225.61 / $1,592.05
| Professional | | $758.12 | $1,225.61 | $1,592.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $821.29 / $952.70 / $1,888.97
| Facility | | $821.29 | $952.70 | $1,888.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,137.18 / $1,137.18 / $1,137.18
| Facility | | $1,137.18 | $1,137.18 | $1,137.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $530.67 / $758.12 / $1,271.05
| Professional | | $530.67 | $758.12 | $1,271.05 |