- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $282.08 / $282.08 / $282.08
| Facility | | $282.08 | $282.08 | $282.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $258.33 / $282.08 / $282.08
| Professional | | $258.33 | $282.08 | $282.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.48 / $337.33 / $876.87
| Professional | | $309.48 | $337.33 | $876.87 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,708.36 / $2,710.46 / $3,592.92
| Facility | | $2,708.36 | $2,710.46 | $3,592.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $256.49 / $346.16 / $1,459.88
| Professional | | $256.49 | $346.16 | $1,459.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $304.58 / $688.39 / $688.39
| Professional | | $304.58 | $688.39 | $688.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.45 / $346.66 / $1,029.77
| Professional | | $282.45 | $346.66 | $1,029.77 |