- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $233.56 / $233.56 / $233.56
| Facility | | $233.56 | $233.56 | $233.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.56 / $233.56 / $2,234.60
| Professional | | $233.56 | $233.56 | $2,234.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,517.61 / $2,196.16 / $3,798.60
| Facility | | $1,517.61 | $2,196.16 | $3,798.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $233.56 / $394.72 / $455.44
| Facility | | $233.56 | $394.72 | $455.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,536.35 / $2,536.35 / $2,536.35
| Professional | | $2,536.35 | $2,536.35 | $2,536.35 |