- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $730.80 / $730.80 / $730.80
| Professional | | $730.80 | $730.80 | $730.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,639.62 / $1,639.62 / $1,639.62
| Facility | | $1,639.62 | $1,639.62 | $1,639.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.66 / $1,639.62 / $2,962.50
| Professional | | $188.66 | $1,639.62 | $2,962.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $906.12 / $1,597.90 / $2,533.25
| Professional | | $906.12 | $1,597.90 | $2,533.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $730.80 / $1,123.40 / $1,623.99
| Professional | | $730.80 | $1,123.40 | $1,623.99 |