- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $341.92 / $420.56 / $420.56
| Facility | | $341.92 | $420.56 | $420.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $334.92 / $351.08 / $420.56
| Professional | | $334.92 | $351.08 | $420.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $472.15 / $720.00 / $1,310.24
| Professional | | $472.15 | $720.00 | $1,310.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $675.40 / $675.40 / $675.40
| Professional | | $675.40 | $675.40 | $675.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $341.92 / $510.11 / $1,267.49
| Facility | | $341.92 | $510.11 | $1,267.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,763.97 / $3,763.97 / $3,763.97
| Professional | | $3,763.97 | $3,763.97 | $3,763.97 |