- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,584.89
| Professional | | $1,412.54 | $1,412.54 | $1,584.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $234.42 / $281.84 / $371.54
| Facility | | $234.42 | $281.84 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,412.54 / $1,412.54
| Facility | | $1,348.96 | $1,412.54 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,412.54 / $1,412.54 / $1,412.54
| Professional | | $1,412.54 | $1,412.54 | $1,412.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.89 / $1,380.38 / $1,445.44
| Professional | | $125.89 | $1,380.38 | $1,445.44 |