- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $655.29 / $655.29 / $655.29
| Professional | | $655.29 | $655.29 | $655.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $618.21 / $1,064.32 / $1,773.87
| Facility | | $618.21 | $1,064.32 | $1,773.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $655.29 / $655.29 / $1,773.87
| Professional | | $655.29 | $655.29 | $1,773.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $618.21 / $1,064.32 / $1,773.87
| Facility | | $618.21 | $1,064.32 | $1,773.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $655.29 / $655.29 / $1,773.87
| Professional | | $655.29 | $655.29 | $1,773.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $655.29 / $655.29 / $1,965.90
| Professional | | $655.29 | $655.29 | $1,965.90 |