- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,821.66 / $1,821.66 / $1,821.66
| Professional | | $1,821.66 | $1,821.66 | $1,821.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,685.49 / $3,685.49 / $3,685.49
| Facility | | $3,685.49 | $3,685.49 | $3,685.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.51 / $3,685.49 / $6,684.84
| Professional | | $192.51 | $3,685.49 | $6,684.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.40 / $473.51 / $3,685.49
| Facility | | $243.40 | $473.51 | $3,685.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.51 / $3,685.49 / $6,684.84
| Professional | | $192.51 | $3,685.49 | $6,684.84 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.44 / $154.44 / $491.58
| Professional | | $154.44 | $154.44 | $491.58 |