- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.13 / $346.56 / $428.91
| Professional | | $343.13 | $346.56 | $428.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,684.20 / $1,684.20 / $1,684.20
| Facility | | $1,684.20 | $1,684.20 | $1,684.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.20 / $479.17 / $3,239.82
| Professional | | $307.20 | $479.17 | $3,239.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $382.67 / $382.67 / $479.17
| Facility | | $382.67 | $382.67 | $479.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $277.87 / $405.36 / $690.54
| Professional | | $277.87 | $405.36 | $690.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $27.40 / $445.80 / $542.40
| Professional | | $27.40 | $445.80 | $542.40 |