- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $339.76 / $340.31 / $340.31
| Facility | | $339.76 | $340.31 | $340.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $340.31 / $340.31 / $357.33
| Professional | | $340.31 | $340.31 | $357.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,863.89 / $8,329.65 / $11,206.05
| Facility | | $6,863.89 | $8,329.65 | $11,206.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $340.31 / $340.31 / $340.31
| Facility | | $340.31 | $340.31 | $340.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $328.91 / $340.31 / $433.08
| Professional | | $328.91 | $340.31 | $433.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $136.12 / $340.31 / $340.31
| Professional | | $136.12 | $340.31 | $340.31 |