- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $869.15 / $869.15 / $984.97
| Professional | | $869.15 | $869.15 | $984.97 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,207.83 / $1,207.83 / $1,207.83
| Facility | | $1,207.83 | $1,207.83 | $1,207.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $881.72 / $881.72 / $1,207.83
| Professional | | $881.72 | $881.72 | $1,207.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,055.55 / $1,055.55 / $1,055.55
| Facility | | $1,055.55 | $1,055.55 | $1,055.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $951.31 / $1,128.89 / $1,587.11
| Professional | | $951.31 | $1,128.89 | $1,587.11 |