- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,530.62 / $1,530.62 / $1,530.62
| Professional | | $1,530.62 | $1,530.62 | $1,530.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $303.33 / $303.33 / $303.33
| Facility | | $303.33 | $303.33 | $303.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.51 / $303.33 / $4,809.12
| Professional | | $192.51 | $303.33 | $4,809.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.40 / $303.33 / $1,768.78
| Facility | | $243.40 | $303.33 | $1,768.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.51 / $303.33 / $4,809.12
| Professional | | $192.51 | $303.33 | $4,809.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.71 / $129.71 / $713.28
| Professional | | $129.71 | $129.71 | $713.28 |