- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $798.40 / $840.47 / $904.79
| Professional | | $798.40 | $840.47 | $904.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,254.96 / $1,254.96 / $1,254.96
| Facility | | $1,254.96 | $1,254.96 | $1,254.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $916.12 / $916.12 / $1,254.96
| Professional | | $916.12 | $916.12 | $1,254.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $969.63 / $969.63 / $969.63
| Facility | | $969.63 | $969.63 | $969.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $873.88 / $1,037.00 / $1,457.92
| Professional | | $873.88 | $1,037.00 | $1,457.92 |