- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.93 / $1,640.93 / $1,640.93
| Professional | | $1,640.93 | $1,640.93 | $1,640.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $364.70 / $364.70 / $1,548.05
| Facility | | $364.70 | $364.70 | $1,548.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $607.83 / $1,640.93 / $1,640.93
| Professional | | $607.83 | $1,640.93 | $1,640.93 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $364.70 / $364.70 / $1,548.05
| Facility | | $364.70 | $364.70 | $1,548.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $607.83 / $1,640.93 / $1,702.85
| Professional | | $607.83 | $1,640.93 | $1,702.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.93 / $1,640.93 / $4,922.79
| Professional | | $1,640.93 | $1,640.93 | $4,922.79 |