- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $368.46 / $368.46 / $368.46
| Facility | | $368.46 | $368.46 | $368.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $368.46 / $379.59 / $379.59
| Professional | | $368.46 | $379.59 | $379.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $527.75 / $641.51 / $1,040.08
| Facility | | $527.75 | $641.51 | $1,040.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,351.47 / $3,351.47 / $3,910.04
| Facility | | $3,351.47 | $3,351.47 | $3,910.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,253.83 / $1,253.83 / $1,253.83
| Professional | | $1,253.83 | $1,253.83 | $1,253.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $7,644.49 / $7,644.49 / $7,644.49
| Professional | | $7,644.49 | $7,644.49 | $7,644.49 |