- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $383.12 / $383.12 / $383.12
| Professional | | $383.12 | $383.12 | $383.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,065.34 / $2,065.34 / $2,065.34
| Facility | | $2,065.34 | $2,065.34 | $2,065.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.73 / $564.14 / $1,771.17
| Professional | | $477.73 | $564.14 | $1,771.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.73 / $564.14 / $1,771.17
| Professional | | $477.73 | $564.14 | $1,771.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $348.62 / $508.50 / $1,884.06
| Professional | | $348.62 | $508.50 | $1,884.06 |