- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $364.00 / $364.00 / $3,343.60
| Professional | | $364.00 | $364.00 | $3,343.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.35 / $870.35 / $870.35
| Facility | | $870.35 | $870.35 | $870.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,168.47 / $1,168.47 / $1,168.47
| Professional | | $1,168.47 | $1,168.47 | $1,168.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $870.35 / $870.35 / $870.35
| Facility | | $870.35 | $870.35 | $870.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.00 / $200.00 / $1,168.47
| Professional | | $200.00 | $200.00 | $1,168.47 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $227.14 / $520.00 / $2,340.00
| Professional | | $227.14 | $520.00 | $2,340.00 |