- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,086.96 / $1,086.96 / $1,121.14
| Professional | | $1,086.96 | $1,086.96 | $1,121.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,638.80 / $1,638.80 / $1,638.80
| Facility | | $1,638.80 | $1,638.80 | $1,638.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,196.32 / $1,196.32 / $1,196.32
| Professional | | $1,196.32 | $1,196.32 | $1,196.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1.94 / $1,203.23 / $1,203.23
| Facility | | $1.94 | $1,203.23 | $1,203.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,005.85 / $1,317.65 / $4,831.38
| Professional | | $1,005.85 | $1,317.65 | $4,831.38 |