- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $362.02 / $388.58 / $459.22
| Professional | | $362.02 | $388.58 | $459.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $649.58 / $649.58
| Professional | | $0.02 | $649.58 | $649.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,687.70 / $1,687.70 / $1,687.70
| Facility | | $1,687.70 | $1,687.70 | $1,687.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $402.96 / $624.61 / $1,091.43
| Professional | | $402.96 | $624.61 | $1,091.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.93 / $485.53 / $691.67
| Professional | | $330.93 | $485.53 | $691.67 |