- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $291.80 / $291.80 / $291.80
| Professional | | $291.80 | $291.80 | $291.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,219.64 / $1,219.64 / $1,219.64
| Facility | | $1,219.64 | $1,219.64 | $1,219.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.18 / $1,219.64 / $2,245.33
| Professional | | $211.18 | $1,219.64 | $2,245.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $298.80 / $1,454.12 / $3,592.53
| Facility | | $298.80 | $1,454.12 | $3,592.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.18 / $1,219.64 / $2,245.33
| Professional | | $211.18 | $1,219.64 | $2,245.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,145.11 / $1,257.65 / $2,096.08
| Professional | | $1,145.11 | $1,257.65 | $2,096.08 |