- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.15 / $707.15 / $7,328.15
| Professional | | $707.15 | $707.15 | $7,328.15 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,460.50 / $1,460.50 / $1,916.91
| Facility | | $1,460.50 | $1,460.50 | $1,916.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,241.43 / $1,460.50 / $2,994.75
| Professional | | $1,241.43 | $1,460.50 | $2,994.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,169.15 / $1,697.15 / $2,451.44
| Professional | | $1,169.15 | $1,697.15 | $2,451.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $707.15 / $1,095.38 / $1,571.45
| Professional | | $707.15 | $1,095.38 | $1,571.45 |