- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $355.61 / $355.61 / $391.17
| Professional | | $355.61 | $355.61 | $391.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,328.40 / $2,328.40 / $2,982.01
| Facility | | $2,328.40 | $2,328.40 | $2,982.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.51 / $440.51 / $440.51
| Professional | | $440.51 | $440.51 | $440.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $440.51 / $440.51 / $440.51
| Professional | | $440.51 | $440.51 | $440.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $494.71 / $520.75 / $1,203.14
| Professional | | $494.71 | $520.75 | $1,203.14 |