- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $345.27 / $345.27 / $345.27
| Facility | | $345.27 | $345.27 | $345.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $320.18 / $345.27 / $509.69
| Professional | | $320.18 | $345.27 | $509.69 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,475.00 / $10,188.53 / $20,811.61
| Facility | | $3,475.00 | $10,188.53 | $20,811.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,758.09 / $2,068.34 / $2,132.31
| Professional | | $1,758.09 | $2,068.34 | $2,132.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $345.27 / $609.39 / $708.21
| Facility | | $345.27 | $609.39 | $708.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $748.68 / $2,436.69 / $2,436.69
| Professional | | $748.68 | $2,436.69 | $2,436.69 |