- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $778.22 / $778.22 / $897.95
| Professional | | $778.22 | $778.22 | $897.95 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,020.64 / $1,020.64 / $1,172.13
| Facility | | $1,020.64 | $1,020.64 | $1,172.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $745.07 / $1,020.64 / $1,051.26
| Professional | | $745.07 | $1,020.64 | $1,051.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,020.64 / $1,020.64 / $1,172.13
| Facility | | $1,020.64 | $1,020.64 | $1,172.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $745.07 / $1,020.64 / $1,051.26
| Professional | | $745.07 | $1,020.64 | $1,051.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $551.62 / $944.68 / $1,843.60
| Professional | | $551.62 | $944.68 | $1,843.60 |