- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.24 / $524.64 / $826.94
| Professional | | $331.24 | $524.64 | $826.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,355.54 / $2,355.54 / $2,355.54
| Facility | | $2,355.54 | $2,355.54 | $2,355.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,203.75 / $2,002.21 / $2,355.54
| Professional | | $1,203.75 | $2,002.21 | $2,355.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $664.24 / $664.24 / $664.24
| Professional | | $664.24 | $664.24 | $664.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $399.27 / $503.64 / $764.50
| Professional | | $399.27 | $503.64 | $764.50 |