- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $576.67 / $576.67 / $576.67
| Professional | | $576.67 | $576.67 | $576.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $396.70 / $396.70 / $396.70
| Facility | | $396.70 | $396.70 | $396.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $148.88 / $396.70 / $2,077.50
| Professional | | $148.88 | $396.70 | $2,077.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $715.10 / $1,261.05 / $1,999.23
| Professional | | $715.10 | $1,261.05 | $1,999.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $541.97 / $886.51 / $1,161.65
| Professional | | $541.97 | $886.51 | $1,161.65 |