- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $319.56 / $319.56 / $319.56
| Professional | | $319.56 | $319.56 | $319.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,689.05 / $1,689.05 / $1,689.05
| Facility | | $1,689.05 | $1,689.05 | $1,689.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.96 / $405.00 / $1,100.61
| Professional | | $354.96 | $405.00 | $1,100.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.96 / $405.00 / $1,100.61
| Professional | | $354.96 | $405.00 | $1,100.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.33 / $312.25 / $601.10
| Professional | | $277.33 | $312.25 | $601.10 |