- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,068.46 / $2,068.46
| Professional | | $2,068.46 | $2,068.46 | $2,068.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.14 / $436.14 / $1,951.39
| Facility | | $436.14 | $436.14 | $1,951.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.14 / $2,068.46 / $2,068.46
| Professional | | $436.14 | $2,068.46 | $2,068.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.14 / $436.14 / $1,951.39
| Facility | | $436.14 | $436.14 | $1,951.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.14 / $2,068.46 / $2,146.53
| Professional | | $436.14 | $2,068.46 | $2,146.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,068.46 / $2,068.46 / $6,205.41
| Professional | | $2,068.46 | $2,068.46 | $6,205.41 |