- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,096.05 / $1,195.78 / $1,355.13
| Professional | | $1,096.05 | $1,195.78 | $1,355.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,523.27 / $1,523.27 / $1,523.27
| Facility | | $1,523.27 | $1,523.27 | $1,523.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,111.99 / $1,111.99 / $1,523.27
| Professional | | $1,111.99 | $1,111.99 | $1,523.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,624.58 / $1,624.58 / $1,624.58
| Facility | | $1,624.58 | $1,624.58 | $1,624.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,308.82 / $1,456.07 / $2,415.92
| Professional | | $1,308.82 | $1,456.07 | $2,415.92 |