- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $389.41 / $389.41 / $389.41
| Professional | | $389.41 | $389.41 | $389.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $1,079.06 / $1,218.22
| Facility | | $0.02 | $1,079.06 | $1,218.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,555.78 / $1,555.78 / $1,555.78
| Facility | | $1,555.78 | $1,555.78 | $1,555.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $604.63 / $604.63 / $755.79
| Professional | | $604.63 | $604.63 | $755.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.18 / $315.74 / $758.98
| Professional | | $184.18 | $315.74 | $758.98 |