- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $308.04 / $308.04 / $308.04
| Facility | | $308.04 | $308.04 | $308.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $272.05 / $308.04 / $308.04
| Professional | | $272.05 | $308.04 | $308.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,282.06 / $3,057.88 / $13,213.43
| Facility | | $1,282.06 | $3,057.88 | $13,213.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,025.65 / $1,282.06 / $1,282.06
| Professional | | $1,025.65 | $1,282.06 | $1,282.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $323.27 / $501.60 / $631.79
| Facility | | $323.27 | $501.60 | $631.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,905.62 / $1,905.62 / $1,905.62
| Professional | | $1,905.62 | $1,905.62 | $1,905.62 |