- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,250.36 / $3,013.88 / $3,013.88
| Professional | | $2,250.36 | $3,013.88 | $3,013.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $303.33 / $303.33 / $303.33
| Facility | | $303.33 | $303.33 | $303.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.83 / $257.83 / $257.83
| Professional | | $257.83 | $257.83 | $257.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $303.33 / $303.33 / $303.33
| Facility | | $303.33 | $303.33 | $303.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.33 / $355.58 / $2,310.88
| Professional | | $100.33 | $355.58 | $2,310.88 |