- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $533.29 / $533.29 / $533.29
| Professional | | $533.29 | $533.29 | $533.29 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,290.69 / $2,290.69 / $2,290.69
| Facility | | $2,290.69 | $2,290.69 | $2,290.69 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.08 / $2,290.69 / $4,828.43
| Professional | | $268.08 | $2,290.69 | $4,828.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $273.61 / $333.08 / $5,826.24
| Facility | | $273.61 | $333.08 | $5,826.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.08 / $2,290.69 / $4,828.43
| Professional | | $268.08 | $2,290.69 | $4,828.43 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.70 / $242.43 / $1,616.21
| Facility | | $218.70 | $242.43 | $1,616.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,385.32 / $1,385.32 / $2,308.87
| Professional | | $1,385.32 | $1,385.32 | $2,308.87 |