- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $223.08 / $223.08 / $223.08
| Facility | | $223.08 | $223.08 | $223.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $73.12 / $214.47 / $223.08
| Professional | | $73.12 | $214.47 | $223.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $317.45 / $792.68 / $12,757.34
| Facility | | $317.45 | $792.68 | $12,757.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $350.12 / $437.65 / $437.65
| Professional | | $350.12 | $437.65 | $437.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $72.73 / $377.01 / $457.41
| Facility | | $72.73 | $377.01 | $457.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,283.58 / $1,283.58 / $1,283.58
| Professional | | $1,283.58 | $1,283.58 | $1,283.58 |