- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $355.87 / $355.87 / $355.87
| Facility | | $355.87 | $355.87 | $355.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $342.09 / $355.87 / $407.72
| Professional | | $342.09 | $355.87 | $407.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,131.62 / $4,300.63 / $8,883.07
| Facility | | $2,131.62 | $4,300.63 | $8,883.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,705.30 / $2,131.62 / $2,131.62
| Professional | | $1,705.30 | $2,131.62 | $2,131.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $245.01 / $601.41 / $729.97
| Facility | | $245.01 | $601.41 | $729.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,390.37 / $2,390.37 / $2,390.37
| Professional | | $2,390.37 | $2,390.37 | $2,390.37 |