- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $668.51 / $668.51 / $835.64
| Professional | | $668.51 | $668.51 | $835.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $787.36 / $3,102.50 / $13,687.50
| Facility | | $787.36 | $3,102.50 | $13,687.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $787.36 / $10,037.50 / $10,037.50
| Professional | | $787.36 | $10,037.50 | $10,037.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $787.36 / $914.39 / $1,519.67
| Facility | | $787.36 | $914.39 | $1,519.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $787.36 / $1,010.45 / $2,045.20
| Professional | | $787.36 | $1,010.45 | $2,045.20 |