- 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 / $368.46 / $368.46
| Professional | | $368.46 | $368.46 | $368.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,024.67 / $9,812.82 / $31,065.37
| Facility | | $8,024.67 | $9,812.82 | $31,065.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $45.00 / $60.00
| Professional | | $45.00 | $45.00 | $60.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $12,019.82 / $15,952.23 / $26,319.12
| Facility | | $12,019.82 | $15,952.23 | $26,319.12 |