- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $477.60 / $477.60 / $477.60
| Professional | | $477.60 | $477.60 | $477.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $738.78 / $1,332.44 / $2,099.54
| Facility | | $738.78 | $1,332.44 | $2,099.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $682.29 / $682.29 / $682.29
| Facility | | $682.29 | $682.29 | $682.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $714.10 / $1,308.66 / $4,817.85
| Facility | | $714.10 | $1,308.66 | $4,817.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.56 / $367.37 / $886.98
| Professional | | $286.56 | $367.37 | $886.98 |