- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $942.40 / $942.40 / $942.40
| Professional | | $942.40 | $942.40 | $942.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,272.05 / $1,272.05 / $1,272.05
| Facility | | $1,272.05 | $1,272.05 | $1,272.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $873.50 / $873.50 / $1,091.86
| Professional | | $873.50 | $873.50 | $1,091.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,272.05 / $1,272.05 / $1,272.05
| Facility | | $1,272.05 | $1,272.05 | $1,272.05 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $494.00 / $873.50 / $1,091.86
| Professional | | $494.00 | $873.50 | $1,091.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $456.00 / $456.00 / $1,064.00
| Professional | | $456.00 | $456.00 | $1,064.00 |