- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $281.84 / $389.05 / $616.60
| Professional | | $281.84 | $389.05 | $616.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,737.80 / $1,737.80 / $1,737.80
| Facility | | $1,737.80 | $1,737.80 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,041.74 / $2,041.74 / $2,041.74
| Facility | | $2,041.74 | $2,041.74 | $2,041.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $389.05 / $1,071.52
| Professional | | $354.81 | $389.05 | $1,071.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $398.11 / $1,148.15
| Professional | | $288.40 | $398.11 | $1,148.15 |