- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $903.21 / $903.21 / $903.21
| Professional | | $903.21 | $903.21 | $903.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,422.41 / $4,422.41 / $5,663.84
| Facility | | $4,422.41 | $4,422.41 | $5,663.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.45 / $903.21 / $903.21
| Professional | | $259.45 | $903.21 | $903.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.45 / $903.21 / $903.21
| Professional | | $259.45 | $903.21 | $903.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $885.50 / $885.50 / $2,045.86
| Professional | | $885.50 | $885.50 | $2,045.86 |