- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $236.62 / $236.62 / $13,260.36
| Facility | | $236.62 | $236.62 | $13,260.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.62 / $236.62 / $283.94
| Professional | | $236.62 | $236.62 | $283.94 |
- 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
- Professional
- Modifier
- Low / Median / High Price
- $236.62 / $236.62 / $236.62
| Professional | | $236.62 | $236.62 | $236.62 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $236.62 / $236.62 / $236.62
| Facility | | $236.62 | $236.62 | $236.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $236.62 / $236.62 / $236.62
| Professional | | $236.62 | $236.62 | $236.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.13 / $236.62 / $258.02
| Professional | | $201.13 | $236.62 | $258.02 |