- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.42 / $418.36 / $418.36
| Professional | | $410.42 | $418.36 | $418.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,362.96 / $2,362.96 / $2,362.96
| Facility | | $2,362.96 | $2,362.96 | $2,362.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $525.30 / $525.30 / $1,770.92
| Professional | | $525.30 | $525.30 | $1,770.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $547.14 / $570.91 / $1,770.92
| Professional | | $547.14 | $570.91 | $1,770.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $547.14 / $570.91 / $1,770.92
| Professional | | $547.14 | $570.91 | $1,770.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $399.27 / $555.25 / $967.18
| Professional | | $399.27 | $555.25 | $967.18 |