- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,156.25 / $2,156.25 / $2,156.25
| Facility | | $2,156.25 | $2,156.25 | $2,156.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.50 / $262.50 / $277.50
| Professional | | $262.50 | $262.50 | $277.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $732.45 / $781.32 / $868.13
| Facility | | $732.45 | $781.32 | $868.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $995.31 / $995.31 / $995.31
| Facility | | $995.31 | $995.31 | $995.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.38 / $219.38 / $219.38
| Professional | | $219.38 | $219.38 | $219.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.50 / $225.00 / $540.86
| Professional | | $157.50 | $225.00 | $540.86 |