- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $408.76 / $563.84 / $563.84
| Professional | | $408.76 | $563.84 | $563.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.00 / $659.87 / $1,335.94
| Professional | | $65.00 | $659.87 | $1,335.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $61.00 / $563.84 / $661.39
| Facility | | $61.00 | $563.84 | $661.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $61.00 / $482.81 / $482.81
| Professional | | $61.00 | $482.81 | $482.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $247.03 / $355.42 / $541.41
| Professional | | $247.03 | $355.42 | $541.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $867.60 / $4,402.87 / $4,402.87
| Facility | | $867.60 | $4,402.87 | $4,402.87 |