- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,056.58 / $1,415.07 / $1,415.07
| Professional | | $1,056.58 | $1,415.07 | $1,415.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,450.41 / $1,450.41 / $1,450.41
| Facility | | $1,450.41 | $1,450.41 | $1,450.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,232.84 / $1,232.84 / $1,232.84
| Professional | | $1,232.84 | $1,232.84 | $1,232.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,450.41 / $1,450.41 / $1,450.41
| Facility | | $1,450.41 | $1,450.41 | $1,450.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $208.95 / $1,100.01 / $1,848.02
| Professional | | $208.95 | $1,100.01 | $1,848.02 |