- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,496.79 / $1,496.79 / $1,496.79
| Professional | | $1,496.79 | $1,496.79 | $1,496.79 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $482.77 / $482.77 / $482.77
| Facility | | $482.77 | $482.77 | $482.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.35 / $410.35 / $410.35
| Professional | | $410.35 | $410.35 | $410.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $482.77 / $482.77 / $482.77
| Facility | | $482.77 | $482.77 | $482.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $410.35 / $410.35 / $1,596.38
| Professional | | $410.35 | $410.35 | $1,596.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.91 / $653.97 / $1,006.01
| Professional | | $291.91 | $653.97 | $1,006.01 |