- 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
- $0.02 / $1,399.08 / $1,554.53
| Facility | | $0.02 | $1,399.08 | $1,554.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $904.03 / $904.03 / $904.03
| Professional | | $904.03 | $904.03 | $904.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,016.96 / $2,016.96 / $2,016.96
| Facility | | $2,016.96 | $2,016.96 | $2,016.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $545.83 / $545.83 / $545.83
| Professional | | $545.83 | $545.83 | $545.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.56 / $682.29 / $984.07
| Professional | | $286.56 | $682.29 | $984.07 |