- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.07 / $240.07 / $240.07
| Professional | | $240.07 | $240.07 | $240.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,001.12 / $1,001.12 / $1,001.12
| Facility | | $1,001.12 | $1,001.12 | $1,001.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,001.12 / $1,001.12 / $1,001.12
| Professional | | $1,001.12 | $1,001.12 | $1,001.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,001.12 / $1,001.12 / $1,001.12
| Facility | | $1,001.12 | $1,001.12 | $1,001.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $420.67 / $494.93 / $1,001.12
| Professional | | $420.67 | $494.93 | $1,001.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.68 / $400.80 / $881.76
| Professional | | $340.68 | $400.80 | $881.76 |