- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,288.25 / $1,412.54 / $2,041.74
| Professional | | $1,288.25 | $1,412.54 | $2,041.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,071.52 / $1,071.52 / $1,071.52
| Facility | | $1,071.52 | $1,071.52 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $912.01 / $912.01 / $1,071.52
| Professional | | $912.01 | $912.01 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,445.44 / $1,445.44 / $1,445.44
| Professional | | $1,445.44 | $1,445.44 | $1,445.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $77.62 / $776.25 / $1,479.11
| Facility | | $77.62 | $776.25 | $1,479.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $812.83 / $1,174.90 / $1,513.56
| Professional | | $812.83 | $1,174.90 | $1,513.56 |