- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $327.83 / $327.83 / $346.56
| Professional | | $327.83 | $327.83 | $346.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $960.34 / $1,084.18
| Facility | | $0.02 | $960.34 | $1,084.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $620.54 / $620.54 / $620.54
| Professional | | $620.54 | $620.54 | $620.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,384.53 / $1,384.53 / $1,384.53
| Facility | | $1,384.53 | $1,384.53 | $1,384.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.70 / $281.00 / $675.47
| Professional | | $196.70 | $281.00 | $675.47 |