- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $451.23 / $650.00 / $4,342.82
| Professional | | $451.23 | $650.00 | $4,342.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,130.45 / $1,130.45 / $1,130.45
| Facility | | $1,130.45 | $1,130.45 | $1,130.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $887.45 / $975.18 / $1,517.14
| Professional | | $887.45 | $975.18 | $1,517.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,130.45 / $1,130.45 / $1,130.45
| Facility | | $1,130.45 | $1,130.45 | $1,130.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $439.01 / $975.18 / $1,517.14
| Professional | | $439.01 | $975.18 | $1,517.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $295.01 / $646.24 / $1,560.44
| Professional | | $295.01 | $646.24 | $1,560.44 |