- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.03 / $933.25 / $2,089.30
| Facility | | $309.03 | $933.25 | $2,089.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $309.03 / $549.54
| Professional | | $309.03 | $309.03 | $549.54 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $331.13 / $331.13 / $371.54
| Professional | | $331.13 | $331.13 | $371.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $309.03 / $309.03 / $309.03
| Facility | | $309.03 | $309.03 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $309.03 / $309.03 / $309.03
| Professional | | $309.03 | $309.03 | $309.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,248.07 / $5,248.07 / $5,248.07
| Facility | | $5,248.07 | $5,248.07 | $5,248.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,025.60 / $6,025.60 / $6,025.60
| Professional | | $6,025.60 | $6,025.60 | $6,025.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $288.40 / $309.03 / $354.81
| Facility | | $288.40 | $309.03 | $354.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $288.40 / $309.03 / $363.08
| Professional | | $288.40 | $309.03 | $363.08 |