- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $437.50 / $437.50 / $437.50
| Professional | | $437.50 | $437.50 | $437.50 |
- 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 / $1,571.25
| Professional | | $106.49 | $833.40 | $1,571.25 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $459.90 / $809.29 / $1,283.02
| Professional | | $459.90 | $809.29 | $1,283.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $437.50 / $668.58 / $972.22
| Professional | | $437.50 | $668.58 | $972.22 |