- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,379.35 / $2,379.35 / $2,379.35
| Facility | | $2,379.35 | $2,379.35 | $2,379.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $528.75 / $528.75 / $528.75
| Professional | | $528.75 | $528.75 | $528.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $254.80 / $254.80 / $254.80
| Facility | | $254.80 | $254.80 | $254.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.90 / $204.21 / $293.56
| Professional | | $117.90 | $204.21 | $293.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.70 / $302.70 / $302.70
| Professional | | $302.70 | $302.70 | $302.70 |