- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,201.60 / $1,201.60 / $1,201.60
| Facility | | $1,201.60 | $1,201.60 | $1,201.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $568.80 / $1,201.60 / $1,201.60
| Professional | | $568.80 | $1,201.60 | $1,201.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $991.62 / $991.62 / $991.62
| Professional | | $991.62 | $991.62 | $991.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $832.50 / $832.50 / $1,519.47
| Facility | | $832.50 | $832.50 | $1,519.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $607.73 / $832.50 / $1,330.51
| Professional | | $607.73 | $832.50 | $1,330.51 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $443.12 / $664.67 / $1,071.33
| Professional | | $443.12 | $664.67 | $1,071.33 |