- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $263.60 / $263.60 / $263.60
| Professional | | $263.60 | $263.60 | $263.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,447.88 / $1,447.88 / $1,447.88
| Facility | | $1,447.88 | $1,447.88 | $1,447.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $388.25 / $444.52 / $1,238.70
| Professional | | $388.25 | $444.52 | $1,238.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $388.25 / $444.52 / $1,238.70
| Professional | | $388.25 | $444.52 | $1,238.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $321.25 / $410.96 / $676.51
| Professional | | $321.25 | $410.96 | $676.51 |