- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,350.35 / $2,350.35 / $2,350.35
| Facility | | $2,350.35 | $2,350.35 | $2,350.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,350.35 / $2,350.35 / $2,350.35
| Professional | | $2,350.35 | $2,350.35 | $2,350.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,685.49 / $3,685.49 / $3,685.49
| Facility | | $3,685.49 | $3,685.49 | $3,685.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $192.51 / $3,685.49 / $3,685.49
| Professional | | $192.51 | $3,685.49 | $3,685.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $82.44 / $145.38 / $230.49
| Professional | | $82.44 | $145.38 | $230.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $154.44 / $154.44 / $1,376.55
| Professional | | $154.44 | $154.44 | $1,376.55 |