- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $646.83 / $7,838.38 / $7,838.38
| Facility | | $646.83 | $7,838.38 | $7,838.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $324.27 / $646.83 / $672.88
| Professional | | $324.27 | $646.83 | $672.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $85.00 / $528.90
| Professional | | $60.00 | $85.00 | $528.90 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,602.00 / $9,127.00 / $10,150.00
| Facility | | $6,602.00 | $9,127.00 | $10,150.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $436.92 / $546.15 / $784.47
| Professional | | $436.92 | $546.15 | $784.47 |