- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $611.41 / $611.41 / $611.41
| Professional | | $611.41 | $611.41 | $611.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,176.76 / $1,176.76 / $1,507.06
| Facility | | $1,176.76 | $1,176.76 | $1,507.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $611.41 / $611.41 / $611.41
| Professional | | $611.41 | $611.41 | $611.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $611.41 / $611.41 / $611.41
| Professional | | $611.41 | $611.41 | $611.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $649.16 / $683.34 / $1,578.79
| Professional | | $649.16 | $683.34 | $1,578.79 |