- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $264.52 / $264.52 / $264.52
| Professional | | $264.52 | $264.52 | $264.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,351.61 / $1,351.61 / $1,351.61
| Facility | | $1,351.61 | $1,351.61 | $1,351.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,195.56 / $2,195.56 / $2,195.56
| Facility | | $2,195.56 | $2,195.56 | $2,195.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.45 / $362.86 / $1,047.09
| Professional | | $286.45 | $362.86 | $1,047.09 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,195.56 / $2,195.56 / $2,195.56
| Facility | | $2,195.56 | $2,195.56 | $2,195.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $286.45 / $362.86 / $1,047.09
| Professional | | $286.45 | $362.86 | $1,047.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.32 / $289.57 / $571.87
| Professional | | $222.32 | $289.57 | $571.87 |