- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $573.45 / $573.45 / $720.56
| Professional | | $573.45 | $573.45 | $720.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,355.54 / $2,355.54 / $2,355.54
| Facility | | $2,355.54 | $2,355.54 | $2,355.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $77.09 / $2,355.54 / $2,355.54
| Professional | | $77.09 | $2,355.54 | $2,355.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $103.87 / $573.45 / $720.56
| Facility | | $103.87 | $573.45 | $720.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $649.64 / $649.64 / $649.64
| Professional | | $649.64 | $649.64 | $649.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $298.30 / $396.53 / $558.83
| Professional | | $298.30 | $396.53 | $558.83 |