- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.50 / $145.50 / $181.88
| Professional | | $145.50 | $145.50 | $181.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,015.58 / $2,015.58 / $2,015.58
| Facility | | $2,015.58 | $2,015.58 | $2,015.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,048.26 / $3,048.26 / $3,048.26
| Professional | | $3,048.26 | $3,048.26 | $3,048.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,799.42 / $1,799.42 / $1,799.42
| Facility | | $1,799.42 | $1,799.42 | $1,799.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,031.26 / $1,445.81 / $2,231.67
| Professional | | $1,031.26 | $1,445.81 | $2,231.67 |