- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $224.00 / $861.06 / $861.06
| Facility | | $224.00 | $861.06 | $861.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $861.06 / $861.06 / $861.06
| Professional | | $861.06 | $861.06 | $861.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $465.86 / $1,144.40 / $1,604.32
| Facility | | $465.86 | $1,144.40 | $1,604.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $335.18 / $335.18 / $335.18
| Professional | | $335.18 | $335.18 | $335.18 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $344.32 / $1,144.40 / $1,604.32
| Facility | | $344.32 | $1,144.40 | $1,604.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $803.66 / $803.66 / $803.66
| Facility | | $803.66 | $803.66 | $803.66 |