- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,052.89 / $1,052.89 / $1,052.89
| Professional | | $1,052.89 | $1,052.89 | $1,052.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $339.83 / $339.83 / $993.29
| Facility | | $339.83 | $339.83 | $993.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $566.38 / $1,052.89 / $1,052.89
| Professional | | $566.38 | $1,052.89 | $1,052.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $339.83 / $339.83 / $993.29
| Facility | | $339.83 | $339.83 | $993.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $566.38 / $1,052.89 / $1,092.61
| Professional | | $566.38 | $1,052.89 | $1,092.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,052.89 / $1,052.89 / $3,158.67
| Professional | | $1,052.89 | $1,052.89 | $3,158.67 |