- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,376.18 / $1,376.18 / $1,376.18
| Professional | | $1,376.18 | $1,376.18 | $1,376.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $734.36 / $734.36 / $734.36
| Professional | | $734.36 | $734.36 | $734.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.05 / $360.77 / $734.36
| Professional | | $192.05 | $360.77 | $734.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.77 / $462.03 / $734.36
| Professional | | $360.77 | $462.03 | $734.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $221.41 / $270.55 / $901.35
| Professional | | $221.41 | $270.55 | $901.35 |