- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $844.14 / $913.79 / $956.63
| Professional | | $844.14 | $913.79 | $956.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,637.27 / $1,637.27 / $1,637.27
| Facility | | $1,637.27 | $1,637.27 | $1,637.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,195.21 / $1,195.21 / $1,637.27
| Professional | | $1,195.21 | $1,195.21 | $1,637.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,366.91 / $1,366.91 / $1,366.91
| Facility | | $1,366.91 | $1,366.91 | $1,366.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $923.94 / $1,156.08 / $3,752.06
| Professional | | $923.94 | $1,156.08 | $3,752.06 |