- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,202.26 / $1,202.26 / $1,202.26
| Professional | | $1,202.26 | $1,202.26 | $1,202.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.03 / $123.03 / $1,548.82
| Professional | | $123.03 | $123.03 | $1,548.82 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $173.78 / $1,258.93
| Facility | | $104.71 | $173.78 | $1,258.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.43 / $123.03 / $2,187.76
| Professional | | $79.43 | $123.03 | $2,187.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58.88 / $588.84 / $1,174.90
| Facility | | $58.88 | $588.84 | $1,174.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $588.84 / $741.31 / $741.31
| Professional | | $588.84 | $741.31 | $741.31 |