- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $655.61 / $655.61 / $655.61
| Facility | | $655.61 | $655.61 | $655.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $655.61 / $1,383.34 / $1,383.34
| Professional | | $655.61 | $1,383.34 | $1,383.34 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $937.52 / $2,337.84 / $3,790.35
| Facility | | $937.52 | $2,337.84 | $3,790.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $986.07 / $986.07 / $1,150.42
| Facility | | $986.07 | $986.07 | $1,150.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,000.00 / $2,000.00 / $2,000.00
| Facility | | $2,000.00 | $2,000.00 | $2,000.00 |