- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $347.38 / $2,784.38 / $2,784.38
| Professional | | $347.38 | $2,784.38 | $2,784.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.89 / $104.89 / $2,626.77
| Facility | | $104.89 | $104.89 | $2,626.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.81 / $2,784.38 / $2,784.38
| Professional | | $174.81 | $2,784.38 | $2,784.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.89 / $104.89 / $2,626.77
| Facility | | $104.89 | $104.89 | $2,626.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $174.81 / $2,784.38 / $2,889.45
| Professional | | $174.81 | $2,784.38 | $2,889.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,784.38 / $2,895.76 / $8,353.14
| Professional | | $2,784.38 | $2,895.76 | $8,353.14 |