- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $263.03 / $263.03 / $263.03
| Facility | | $263.03 | $263.03 | $263.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $302.00 / $436.52
| Professional | | $245.47 | $302.00 | $436.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $436.52 / $436.52 / $1,698.24
| Facility | | $436.52 | $436.52 | $1,698.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $251.19 / $870.96 / $1,318.26
| Professional | | $251.19 | $870.96 | $1,318.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,630.78 / $3,630.78 / $3,630.78
| Facility | | $3,630.78 | $3,630.78 | $3,630.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.55 / $251.19 / $524.81
| Professional | | $190.55 | $251.19 | $524.81 |