- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,640.40 / $1,640.40 / $1,640.40
| Professional | | $1,640.40 | $1,640.40 | $1,640.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,225.09 / $2,225.09 / $2,225.09
| Facility | | $2,225.09 | $2,225.09 | $2,225.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $246.17 / $2,225.09 / $3,768.75
| Professional | | $246.17 | $2,225.09 | $3,768.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $60.00
| Professional | | $60.00 | $60.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $231.47 / $1,106.56 / $2,016.78
| Professional | | $231.47 | $1,106.56 | $2,016.78 |