- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.72 / $336.72 / $336.72
| Professional | | $336.72 | $336.72 | $336.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,677.12 / $1,677.12 / $1,677.12
| Facility | | $1,677.12 | $1,677.12 | $1,677.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.13 / $480.39 / $1,341.41
| Professional | | $326.13 | $480.39 | $1,341.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $326.13 / $480.39 / $1,341.41
| Professional | | $326.13 | $480.39 | $1,341.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.80 / $331.20 / $732.60
| Professional | | $230.80 | $331.20 | $732.60 |