- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.93 / $222.93 / $4,948.39
| Professional | | $222.93 | $222.93 | $4,948.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.08 / $1,288.08 / $1,288.08
| Facility | | $1,288.08 | $1,288.08 | $1,288.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,728.78 / $1,728.78 / $1,728.78
| Professional | | $1,728.78 | $1,728.78 | $1,728.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,288.08 / $1,288.08 / $1,288.08
| Facility | | $1,288.08 | $1,288.08 | $1,288.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.23 / $500.23 / $1,728.78
| Professional | | $500.23 | $500.23 | $1,728.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.15 / $769.58 / $3,463.11
| Professional | | $336.15 | $769.58 | $3,463.11 |