- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.15 / $269.15 / $269.15
| Facility | | $269.15 | $269.15 | $269.15 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $194.98 / $257.04 / $346.74
| Professional | | $194.98 | $257.04 | $346.74 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,265.80 / $7,585.78 / $22,908.68
| Facility | | $4,265.80 | $7,585.78 | $22,908.68 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,348.96 / $1,698.24 / $1,698.24
| Professional | | $1,348.96 | $1,698.24 | $1,698.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $269.15 / $371.54 / $549.54
| Facility | | $269.15 | $371.54 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,698.24 / $1,698.24 / $1,698.24
| Professional | | $1,698.24 | $1,698.24 | $1,698.24 |