- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $917.34 / $917.34 / $917.34
| Professional | | $917.34 | $917.34 | $917.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,450.41 / $1,450.41 / $1,450.41
| Facility | | $1,450.41 | $1,450.41 | $1,450.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.74 / $1,232.84 / $3,787.50
| Professional | | $184.74 | $1,232.84 | $3,787.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $887.31 / $1,564.73 / $2,480.67
| Professional | | $887.31 | $1,564.73 | $2,480.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $600.19 / $1,100.01 / $1,333.76
| Professional | | $600.19 | $1,100.01 | $1,333.76 |