- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.47 / $245.47 / $245.47
| Professional | | $245.47 | $245.47 | $245.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,137.96 / $2,570.40 / $2,951.21
| Facility | | $2,137.96 | $2,570.40 | $2,951.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $354.81 / $1,995.26 / $2,754.23
| Professional | | $354.81 | $1,995.26 | $2,754.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $645.65 / $645.65 / $645.65
| Facility | | $645.65 | $645.65 | $645.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $891.25 / $1,479.11 / $10,964.78
| Facility | | $891.25 | $1,479.11 | $10,964.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $891.25 / $1,479.11 / $10,964.78
| Professional | | $891.25 | $1,479.11 | $10,964.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.78 / $1,148.15 / $2,398.83
| Facility | | $218.78 | $1,148.15 | $2,398.83 |