- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.60 / $477.60 / $477.60
| Professional | | $477.60 | $477.60 | $477.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,122.36 / $1,320.78 / $3,397.33
| Facility | | $1,122.36 | $1,320.78 | $3,397.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.92 / $443.48 / $443.49
| Professional | | $272.92 | $443.48 | $443.49 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,232.02 / $2,494.62 / $2,993.11
| Facility | | $1,232.02 | $2,494.62 | $2,993.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $682.29 / $990.28 / $2,247.53
| Professional | | $682.29 | $990.28 | $2,247.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.56 / $409.37 / $682.29
| Professional | | $286.56 | $409.37 | $682.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $509.47 / $560.41 / $713.26
| Professional | | $509.47 | $560.41 | $713.26 |