- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $921.82 / $921.82 / $921.82
| Professional | | $921.82 | $921.82 | $921.82 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $642.27 / $1,328.22 / $2,803.55
| Professional | | $642.27 | $1,328.22 | $2,803.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $901.20 / $901.20 / $967.91
| Facility | | $901.20 | $901.20 | $967.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.55 / $653.66 / $925.69
| Professional | | $167.55 | $653.66 | $925.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $167.55 / $925.69 / $925.69
| Professional | | $167.55 | $925.69 | $925.69 |