- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.86 / $375.86 / $375.86
| Facility | | $375.86 | $375.86 | $375.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $375.86 / $375.86 / $448.03
| Professional | | $375.86 | $375.86 | $448.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $896.35 / $896.35 / $1,115.46
| Facility | | $896.35 | $896.35 | $1,115.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.61 / $346.19 / $988.92
| Professional | | $245.61 | $346.19 | $988.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $100.00
| Facility | | $100.00 | $100.00 | $100.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $290.26 / $294.49 / $321.45
| Professional | | $290.26 | $294.49 | $321.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,758.40 / $6,758.40 / $6,758.40
| Professional | | $6,758.40 | $6,758.40 | $6,758.40 |