- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $750.83 / $814.73 / $867.80
| Professional | | $750.83 | $814.73 | $867.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,573.58 / $1,573.58 / $1,573.58
| Facility | | $1,573.58 | $1,573.58 | $1,573.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,148.71 / $1,148.71 / $1,573.58
| Professional | | $1,148.71 | $1,148.71 | $1,573.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,261.08 / $1,261.08 / $1,261.08
| Facility | | $1,261.08 | $1,261.08 | $1,261.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $821.80 / $975.21 / $1,392.81
| Professional | | $821.80 | $975.21 | $1,392.81 |