- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,055.22 / $1,413.25 / $1,459.78
| Professional | | $1,055.22 | $1,413.25 | $1,459.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,217.05 / $1,217.05 / $1,629.32
| Facility | | $1,217.05 | $1,217.05 | $1,629.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,034.49 / $1,034.49 / $1,034.49
| Professional | | $1,034.49 | $1,034.49 | $1,034.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,217.05 / $1,217.05 / $1,629.32
| Facility | | $1,217.05 | $1,217.05 | $1,629.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $668.61 / $1,441.28 / $1,886.22
| Professional | | $668.61 | $1,441.28 | $1,886.22 |