- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $971.60 / $971.60 / $1,663.80
| Professional | | $971.60 | $971.60 | $1,663.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,855.60 / $1,855.60 / $1,855.60
| Facility | | $1,855.60 | $1,855.60 | $1,855.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,855.60 / $1,855.60 / $1,855.60
| Professional | | $1,855.60 | $1,855.60 | $1,855.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.87 / $109.87 / $109.87
| Facility | | $109.87 | $109.87 | $109.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $93.39 / $93.39 / $109.87
| Professional | | $93.39 | $93.39 | $109.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $74.48 / $82.40 / $892.71
| Professional | | $74.48 | $82.40 | $892.71 |