- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $421.47 / $746.60 / $3,844.56
| Professional | | $421.47 | $746.60 | $3,844.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.75 / $1,000.75 / $1,000.75
| Facility | | $1,000.75 | $1,000.75 | $1,000.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $686.82 / $858.52 / $1,343.62
| Professional | | $686.82 | $858.52 | $1,343.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.75 / $1,000.75 / $1,000.75
| Facility | | $1,000.75 | $1,000.75 | $1,000.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $388.64 / $686.82 / $1,343.62
| Professional | | $388.64 | $686.82 | $1,343.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.17 / $361.26 / $1,381.41
| Professional | | $261.17 | $361.26 | $1,381.41 |