- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,198.63 / $1,261.79 / $1,358.35
| Professional | | $1,198.63 | $1,261.79 | $1,358.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,819.89 / $1,819.89 / $1,819.89
| Facility | | $1,819.89 | $1,819.89 | $1,819.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,328.52 / $1,328.52 / $1,819.89
| Professional | | $1,328.52 | $1,328.52 | $1,819.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,776.27 / $1,776.27 / $1,776.27
| Facility | | $1,776.27 | $1,776.27 | $1,776.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,311.94 / $1,556.83 / $2,223.48
| Professional | | $1,311.94 | $1,556.83 | $2,223.48 |