- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $431.54 / $2,412.86 / $2,412.86
| Professional | | $431.54 | $2,412.86 | $2,412.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $544.11 / $637.92 / $2,138.92
| Facility | | $544.11 | $637.92 | $2,138.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.26 / $544.11 / $544.11
| Professional | | $177.26 | $544.11 | $544.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $544.11 / $637.92 / $2,138.92
| Facility | | $544.11 | $637.92 | $2,138.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $337.73 / $337.73 / $544.11
| Professional | | $337.73 | $337.73 | $544.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.61 / $157.61 / $375.25
| Professional | | $157.61 | $157.61 | $375.25 |