- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.27 / $230.27 / $230.27
| Professional | | $230.27 | $230.27 | $230.27 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,023.33 / $2,244.42 / $2,347.65
| Facility | | $1,023.33 | $2,244.42 | $2,347.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $350.35 / $350.35 / $350.35
| Facility | | $350.35 | $350.35 | $350.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.19 / $186.33 / $300.45
| Professional | | $84.19 | $186.33 | $300.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $350.35 / $350.35 / $350.35
| Facility | | $350.35 | $350.35 | $350.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $84.19 / $186.33 / $300.45
| Professional | | $84.19 | $186.33 | $300.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $87.15 / $115.63 / $296.45
| Professional | | $87.15 | $115.63 | $296.45 |