- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $957.35 / $957.35 / $957.35
| Professional | | $957.35 | $957.35 | $957.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,363.57 / $1,363.57 / $1,363.57
| Facility | | $1,363.57 | $1,363.57 | $1,363.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,482.94 / $1,482.94 / $1,482.94
| Professional | | $1,482.94 | $1,482.94 | $1,482.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,653.92 / $1,731.85 / $1,731.85
| Professional | | $1,653.92 | $1,731.85 | $1,731.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,653.92 / $1,653.92 / $1,653.92
| Professional | | $1,653.92 | $1,653.92 | $1,653.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,169.33 / $1,363.57 / $1,973.31
| Professional | | $1,169.33 | $1,363.57 | $1,973.31 |