- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $840.65 / $840.65 / $840.65
| Professional | | $840.65 | $840.65 | $840.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,050.81 / $1,303.00 / $2,690.00
| Professional | | $1,050.81 | $1,303.00 | $2,690.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,681.15 / $1,681.15 / $1,681.15
| Facility | | $1,681.15 | $1,681.15 | $1,681.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $966.01 / $966.01 / $1,207.51
| Professional | | $966.01 | $966.01 | $1,207.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $353.07 / $353.07 / $840.65
| Professional | | $353.07 | $353.07 | $840.65 |