- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $504.69 / $504.69 / $504.69
| Professional | | $504.69 | $504.69 | $504.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,409.71 / $2,409.71 / $2,409.71
| Facility | | $2,409.71 | $2,409.71 | $2,409.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.60 / $830.65 / $2,715.94
| Professional | | $524.60 | $830.65 | $2,715.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $524.60 / $830.65 / $2,715.94
| Professional | | $524.60 | $830.65 | $2,715.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $343.83 / $593.47 / $2,889.05
| Professional | | $343.83 | $593.47 | $2,889.05 |