- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $833.40 / $833.40 / $833.40
| Facility | | $833.40 | $833.40 | $833.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.49 / $833.40 / $1,200.98
| Professional | | $106.49 | $833.40 | $1,200.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $777.78 / $1,144.44 / $1,921.57
| Facility | | $777.78 | $1,144.44 | $1,921.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.49 / $833.40 / $1,200.98
| Professional | | $106.49 | $833.40 | $1,200.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $612.50 / $668.58 / $1,114.30
| Professional | | $612.50 | $668.58 | $1,114.30 |