- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $376.81 / $417.54 / $417.54
| Professional | | $376.81 | $417.54 | $417.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $1,044.14 / $1,178.80
| Facility | | $0.02 | $1,044.14 | $1,178.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,505.25 / $1,505.25 / $1,505.25
| Facility | | $1,505.25 | $1,505.25 | $1,505.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $585.22 / $585.22 / $731.53
| Professional | | $585.22 | $585.22 | $731.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.86 / $289.41 / $734.42
| Professional | | $213.86 | $289.41 | $734.42 |