- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $514.44 / $514.44 / $514.44
| Professional | | $514.44 | $514.44 | $514.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,798.42 / $2,798.42 / $2,798.42
| Facility | | $2,798.42 | $2,798.42 | $2,798.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $651.54 / $742.11 / $2,324.96
| Professional | | $651.54 | $742.11 | $2,324.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $651.54 / $742.11 / $2,324.96
| Professional | | $651.54 | $742.11 | $2,324.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $475.46 / $701.64 / $2,473.16
| Professional | | $475.46 | $701.64 | $2,473.16 |