- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $494.91 / $876.70 / $4,349.89
| Professional | | $494.91 | $876.70 | $4,349.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,132.30 / $1,132.30 / $1,132.30
| Facility | | $1,132.30 | $1,132.30 | $1,132.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.78 / $800.75 / $1,520.39
| Professional | | $336.78 | $800.75 | $1,520.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,132.30 / $1,132.30 / $1,132.30
| Facility | | $1,132.30 | $1,132.30 | $1,132.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.78 / $800.75 / $1,520.39
| Professional | | $336.78 | $800.75 | $1,520.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.50 / $781.29 / $3,044.25
| Professional | | $295.50 | $781.29 | $3,044.25 |