- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $793.61 / $861.16 / $928.49
| Professional | | $793.61 | $861.16 | $928.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,132.82 / $1,132.82 / $1,132.82
| Facility | | $1,132.82 | $1,132.82 | $1,132.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $826.96 / $826.96 / $826.96
| Professional | | $826.96 | $826.96 | $826.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,052.80 / $1,052.80 / $1,052.80
| Facility | | $1,052.80 | $1,052.80 | $1,052.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $641.36 / $966.36 / $1,449.17
| Professional | | $641.36 | $966.36 | $1,449.17 |