- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $741.04 / $741.04 / $855.05
| Professional | | $741.04 | $741.04 | $855.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,116.13 / $1,149.77 / $1,149.77
| Facility | | $1,116.13 | $1,149.77 | $1,149.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $839.33 / $1,149.77 / $1,184.26
| Professional | | $839.33 | $1,149.77 | $1,184.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,116.13 / $1,149.77 / $1,149.77
| Facility | | $1,116.13 | $1,149.77 | $1,149.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $839.33 / $1,149.77 / $1,184.26
| Professional | | $839.33 | $1,149.77 | $1,184.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.26 / $939.69 / $1,755.52
| Professional | | $525.26 | $939.69 | $1,755.52 |