- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $371.54
| Facility | | $371.54 | $371.54 | $371.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $371.54 / $371.54 / $380.19
| Professional | | $371.54 | $371.54 | $380.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,630.78 / $7,079.46
| Facility | | $2,754.23 | $3,630.78 | $7,079.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,818.38 / $4,168.69 / $8,317.64
| Professional | | $2,818.38 | $4,168.69 | $8,317.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $331.13 / $707.95 / $12,882.50
| Facility | | $331.13 | $707.95 | $12,882.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,754.40 / $9,549.93 / $12,589.25
| Facility | | $5,754.40 | $9,549.93 | $12,589.25 |