- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.11 / $794.33 / $794.33
| Professional | | $85.11 | $794.33 | $794.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,380.38 / $1,380.38 / $1,380.38
| Facility | | $1,380.38 | $1,380.38 | $1,380.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,584.89 / $1,584.89 / $1,584.89
| Facility | | $1,584.89 | $1,584.89 | $1,584.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $288.40 / $616.60
| Professional | | $288.40 | $288.40 | $616.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $794.33
| Professional | | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.52 / $436.52 / $489.78
| Professional | | $436.52 | $436.52 | $489.78 |