- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $346.55 / $1,937.68 / $1,937.68
| Professional | | $346.55 | $1,937.68 | $1,937.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.96 / $512.29 / $1,717.70
| Facility | | $436.96 | $512.29 | $1,717.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.96 / $436.96 / $436.96
| Professional | | $436.96 | $436.96 | $436.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.96 / $512.29 / $1,717.70
| Facility | | $436.96 | $512.29 | $1,717.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.22 / $271.22 / $436.96
| Professional | | $271.22 | $271.22 | $436.96 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $126.57 / $126.57 / $301.35
| Professional | | $126.57 | $126.57 | $301.35 |