- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $835.09 / $905.58 / $946.37
| Professional | | $835.09 | $905.58 | $946.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,650.90 / $1,650.90 / $1,650.90
| Facility | | $1,650.90 | $1,650.90 | $1,650.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,403.27 / $1,403.27 / $1,650.90
| Professional | | $1,403.27 | $1,403.27 | $1,650.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2.29 / $1,224.69 / $1,224.69
| Facility | | $2.29 | $1,224.69 | $1,224.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,012.32 / $1,680.77 / $3,711.84
| Professional | | $1,012.32 | $1,680.77 | $3,711.84 |