- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.38 / $150.38 / $150.38
| Facility | | $150.38 | $150.38 | $150.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.16 / $150.38 / $196.03
| Professional | | $140.16 | $150.38 | $196.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,013.11 / $1,775.57 / $3,715.45
| Facility | | $1,013.11 | $1,775.57 | $3,715.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $755.20 / $944.00 / $944.00
| Professional | | $755.20 | $944.00 | $944.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $208.74 / $309.51 / $405.35
| Facility | | $208.74 | $309.51 | $405.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,307.34 / $1,307.34 / $1,307.34
| Professional | | $1,307.34 | $1,307.34 | $1,307.34 |