- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $973.21 / $973.21 / $973.21
| Professional | | $973.21 | $973.21 | $973.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,227.08 / $1,227.08 / $1,227.08
| Facility | | $1,227.08 | $1,227.08 | $1,227.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,227.08 / $1,227.08 / $1,227.08
| Professional | | $1,227.08 | $1,227.08 | $1,227.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,227.08 / $1,227.08 / $1,227.08
| Facility | | $1,227.08 | $1,227.08 | $1,227.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $761.64 / $761.64 / $1,227.08
| Professional | | $761.64 | $761.64 | $1,227.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $355.43 / $355.43 / $846.27
| Professional | | $355.43 | $355.43 | $846.27 |