- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $583.41 / $583.41 / $583.41
| Facility | | $583.41 | $583.41 | $583.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $836.47 / $836.47 / $1,032.19
| Professional | | $836.47 | $836.47 | $1,032.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,032.63 / $1,257.33 / $1,696.40
| Facility | | $1,032.63 | $1,257.33 | $1,696.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $0.02
| Professional | | $0.02 | $0.02 | $0.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.74 / $360.74 / $360.74
| Professional | | $360.74 | $360.74 | $360.74 |