- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $655.61 / $655.61 / $655.61
| Facility | | $655.61 | $655.61 | $655.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $655.61 / $655.61 / $655.61
| Professional | | $655.61 | $655.61 | $655.61 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,399.01 / $4,757.87 / $10,111.83
| Facility | | $2,399.01 | $4,757.87 | $10,111.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $655.61 / $2,296.00 / $5,920.00
| Facility | | $655.61 | $2,296.00 | $5,920.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,296.00 / $3,500.00 / $6,361.00
| Facility | | $2,296.00 | $3,500.00 | $6,361.00 |