- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $835.56 / $835.56 / $835.56
| Professional | | $835.56 | $835.56 | $835.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,195.72 / $1,195.72 / $1,195.72
| Facility | | $1,195.72 | $1,195.72 | $1,195.72 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,800.00 / $1,800.00 / $1,800.00
| Professional | | $1,800.00 | $1,800.00 | $1,800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,450.65 / $1,519.00 / $1,519.00
| Professional | | $1,450.65 | $1,519.00 | $1,519.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,450.65 / $1,450.65 / $1,450.65
| Professional | | $1,450.65 | $1,450.65 | $1,450.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,093.69 / $1,195.72 / $1,730.78
| Professional | | $1,093.69 | $1,195.72 | $1,730.78 |