- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $271.60 / $271.60 / $649.88
| Facility | | $271.60 | $271.60 | $649.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $261.08 / $271.60 / $271.60
| Professional | | $261.08 | $271.60 | $271.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $403.26 / $1,348.10 / $3,255.16
| Facility | | $403.26 | $1,348.10 | $3,255.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $818.76 / $1,023.45 / $1,023.45
| Professional | | $818.76 | $1,023.45 | $1,023.45 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $330.15 / $459.00 / $556.98
| Facility | | $330.15 | $459.00 | $556.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,733.46 / $1,733.46 / $1,733.46
| Professional | | $1,733.46 | $1,733.46 | $1,733.46 |