- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $243.24 / $243.24 / $243.24
| Facility | | $243.24 | $243.24 | $243.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $233.83 / $243.24 / $424.84
| Professional | | $233.83 | $243.24 | $424.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,963.76 / $5,031.64 / $12,757.34
| Facility | | $1,963.76 | $5,031.64 | $12,757.34 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,571.01 / $1,963.76 / $1,963.76
| Professional | | $1,571.01 | $1,963.76 | $1,963.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $381.89 / $499.49 / $881.94
| Facility | | $381.89 | $499.49 | $881.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,713.22 / $2,713.22 / $2,713.22
| Professional | | $2,713.22 | $2,713.22 | $2,713.22 |