- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $267.38 / $267.38 / $267.38
| Facility | | $267.38 | $267.38 | $267.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.06 / $267.38 / $267.38
| Professional | | $257.06 | $267.38 | $267.38 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,374.53 / $6,432.58 / $12,629.62
| Facility | | $3,374.53 | $6,432.58 | $12,629.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,343.25 / $1,679.06 / $1,679.06
| Professional | | $1,343.25 | $1,679.06 | $1,679.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $330.15 / $451.87 / $548.12
| Facility | | $330.15 | $451.87 | $548.12 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,712.50 / $1,712.50 / $1,712.50
| Professional | | $1,712.50 | $1,712.50 | $1,712.50 |