- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $890.77 / $890.77 / $890.77
| Professional | | $890.77 | $890.77 | $890.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,613.29 / $3,613.29 / $3,613.29
| Facility | | $3,613.29 | $3,613.29 | $3,613.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $839.78 / $1,070.94 / $2,946.88
| Professional | | $839.78 | $1,070.94 | $2,946.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $839.78 / $1,070.94 / $2,946.88
| Professional | | $839.78 | $1,070.94 | $2,946.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.57 / $661.36 / $3,134.70
| Professional | | $350.57 | $661.36 | $3,134.70 |