- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $464.63 / $464.63 / $464.63
| Professional | | $464.63 | $464.63 | $464.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,042.44 / $1,042.44 / $1,042.44
| Facility | | $1,042.44 | $1,042.44 | $1,042.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $119.94 / $886.07 / $2,090.63
| Professional | | $119.94 | $886.07 | $2,090.63 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $489.67 / $863.50 / $1,368.97
| Professional | | $489.67 | $863.50 | $1,368.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.75 / $714.14 / $935.80
| Professional | | $436.75 | $714.14 | $935.80 |