- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $502.32 / $545.76 / $682.20
| Professional | | $502.32 | $545.76 | $682.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,013.42 / $2,355.54 / $2,355.54
| Facility | | $1,013.42 | $2,355.54 | $2,355.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.42 / $2,002.21 / $2,355.54
| Professional | | $73.42 | $2,002.21 | $2,355.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.67 / $103.87 / $4,660.41
| Facility | | $64.67 | $103.87 | $4,660.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $323.73 / $480.60 / $743.08
| Professional | | $323.73 | $480.60 | $743.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $364.33 / $480.60 / $743.08
| Professional | | $364.33 | $480.60 | $743.08 |