- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $519.35 / $519.35 / $900.70
| Professional | | $519.35 | $519.35 | $900.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,004.60 / $1,004.60 / $1,004.60
| Professional | | $1,004.60 | $1,004.60 | $1,004.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $855.35 / $855.35 / $2,355.54
| Facility | | $855.35 | $855.35 | $2,355.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,355.54 / $2,355.54 / $2,355.54
| Professional | | $2,355.54 | $2,355.54 | $2,355.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $365.24 / $431.65 / $703.66
| Professional | | $365.24 | $431.65 | $703.66 |