- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $571.27 / $571.27 / $571.27
| Professional | | $571.27 | $571.27 | $571.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.02 / $1,582.99 / $1,787.13
| Facility | | $0.02 | $1,582.99 | $1,787.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,282.08 / $2,282.08 / $2,282.08
| Facility | | $2,282.08 | $2,282.08 | $2,282.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $887.12 / $887.12 / $1,108.91
| Professional | | $887.12 | $887.12 | $1,108.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $270.19 / $463.19 / $1,113.43
| Professional | | $270.19 | $463.19 | $1,113.43 |