- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.31 / $302.31 / $302.31
| Professional | | $302.31 | $302.31 | $302.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,406.76 / $1,406.76 / $1,406.76
| Facility | | $1,406.76 | $1,406.76 | $1,406.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.80 / $1,406.76 / $2,326.52
| Professional | | $218.80 | $1,406.76 | $2,326.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.57 / $1,506.70 / $3,722.43
| Facility | | $309.57 | $1,506.70 | $3,722.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $218.80 / $1,406.76 / $2,326.52
| Professional | | $218.80 | $1,406.76 | $2,326.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,186.52 / $1,302.91 / $2,171.51
| Professional | | $1,186.52 | $1,302.91 | $2,171.51 |