- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $550.03 / $755.48 / $1,486.92
| Professional | | $550.03 | $755.48 | $1,486.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $860.04 / $860.04 / $860.04
| Facility | | $860.04 | $860.04 | $860.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $731.03 / $860.04 / $2,081.25
| Professional | | $731.03 | $860.04 | $2,081.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,100.80 / $3,100.80 / $3,100.80
| Professional | | $3,100.80 | $3,100.80 | $3,100.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.72 / $1,194.40 / $1,194.40
| Professional | | $60.72 | $1,194.40 | $1,194.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $632.51 / $881.67 / $1,653.43
| Professional | | $632.51 | $881.67 | $1,653.43 |