- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $104.71 / $162.18 / $162.18
| Facility | | $104.71 | $162.18 | $162.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $104.71 / $173.78 / $223.87
| Professional | | $104.71 | $173.78 | $223.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.83 / $177.83 / $177.83
| Professional | | $177.83 | $177.83 | $177.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,715.35 / $3,715.35 / $3,715.35
| Facility | | $3,715.35 | $3,715.35 | $3,715.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $1,995.26 / $1,995.26
| Professional | | $1,318.26 | $1,995.26 | $1,995.26 |