- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $449.76 / $449.76 / $449.76
| Professional | | $449.76 | $449.76 | $449.76 |
- 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
- $73.42 / $2,355.54 / $2,355.54
| Professional | | $73.42 | $2,355.54 | $2,355.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $60.00
| Professional | | $60.00 | $60.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $332.72 / $437.19 / $743.08
| Professional | | $332.72 | $437.19 | $743.08 |