- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $421.47 / $746.60 / $4,886.80
| Professional | | $421.47 | $746.60 | $4,886.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,272.05 / $1,272.05 / $1,272.05
| Facility | | $1,272.05 | $1,272.05 | $1,272.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.74 / $684.15 / $1,707.70
| Professional | | $287.74 | $684.15 | $1,707.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,272.05 / $1,272.05 / $1,272.05
| Facility | | $1,272.05 | $1,272.05 | $1,272.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $287.74 / $684.15 / $1,707.70
| Professional | | $287.74 | $684.15 | $1,707.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.97 / $602.10 / $1,755.90
| Professional | | $331.97 | $602.10 | $1,755.90 |