- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $876.91 / $876.91 / $876.91
| Professional | | $876.91 | $876.91 | $876.91 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,587.01 / $5,587.01 / $5,587.01
| Facility | | $5,587.01 | $5,587.01 | $5,587.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.05 / $5,587.01 / $6,397.08
| Professional | | $615.05 | $5,587.01 | $6,397.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $362.50 / $745.54 / $7,719.20
| Facility | | $362.50 | $745.54 | $7,719.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.05 / $5,587.01 / $6,397.08
| Professional | | $615.05 | $5,587.01 | $6,397.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,460.48 / $2,487.88 / $4,146.47
| Professional | | $2,460.48 | $2,487.88 | $4,146.47 |