- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $604.66 / $604.66 / $604.66
| Professional | | $604.66 | $604.66 | $604.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,534.77 / $2,534.77 / $3,148.29
| Facility | | $2,534.77 | $2,534.77 | $3,148.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $628.37 / $628.37 / $678.53
| Professional | | $628.37 | $628.37 | $678.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $628.37 / $628.37 / $678.53
| Professional | | $628.37 | $628.37 | $678.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $592.79 / $628.37 / $1,369.61
| Professional | | $592.79 | $628.37 | $1,369.61 |