- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $505.45 / $2,950.45 / $2,950.45
| Professional | | $505.45 | $2,950.45 | $2,950.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $923.83 / $923.83 / $923.83
| Facility | | $923.83 | $923.83 | $923.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $645.00 / $923.83 / $923.83
| Professional | | $645.00 | $923.83 | $923.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $452.54 / $926.25 / $966.46
| Facility | | $452.54 | $926.25 | $966.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $558.67 / $838.11 / $1,208.90
| Professional | | $558.67 | $838.11 | $1,208.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $790.07 / $974.99 / $1,617.83
| Professional | | $790.07 | $974.99 | $1,617.83 |