- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,155.32 / $1,512.85 / $1,512.85
| Professional | | $1,155.32 | $1,512.85 | $1,512.85 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,736.19 / $1,736.19 / $1,736.19
| Facility | | $1,736.19 | $1,736.19 | $1,736.19 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $879.76 / $1,304.88 / $1,755.89
| Professional | | $879.76 | $1,304.88 | $1,755.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $920.98 / $1,498.82 / $1,906.36
| Facility | | $920.98 | $1,498.82 | $1,906.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,041.34 / $1,562.18 / $2,054.92
| Professional | | $1,041.34 | $1,562.18 | $2,054.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.81 / $1,732.63 / $1,960.97
| Professional | | $1,308.81 | $1,732.63 | $1,960.97 |