- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $883.01 / $883.01 / $883.01
| Professional | | $883.01 | $883.01 | $883.01 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,212.85 / $1,212.85 / $1,212.85
| Facility | | $1,212.85 | $1,212.85 | $1,212.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,188.15 / $1,435.95 / $1,952.73
| Professional | | $1,188.15 | $1,435.95 | $1,952.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,212.85 / $1,212.85 / $1,212.85
| Facility | | $1,212.85 | $1,212.85 | $1,212.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,124.97 / $1,225.97 / $1,952.73
| Professional | | $1,124.97 | $1,225.97 | $1,952.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $888.63 / $1,265.39 / $4,115.25
| Professional | | $888.63 | $1,265.39 | $4,115.25 |