- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $545.54 / $668.50 / $4,349.89
| Professional | | $545.54 | $668.50 | $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
- $1,073.11 / $1,178.97 / $1,520.39
| Professional | | $1,073.11 | $1,178.97 | $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
- $459.56 / $1,178.97 / $1,520.39
| Professional | | $459.56 | $1,178.97 | $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 |