- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $474.47 / $474.47 / $3,355.80
| Professional | | $474.47 | $474.47 | $3,355.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $394.97 / $394.97 / $394.97
| Facility | | $394.97 | $394.97 | $394.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.33 / $394.97 / $1,311.75
| Professional | | $288.33 | $394.97 | $1,311.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $494.23 / $717.44 / $1,036.30
| Professional | | $494.23 | $717.44 | $1,036.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $388.20 / $548.04 / $862.67
| Professional | | $388.20 | $548.04 | $862.67 |