- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $222.04 / $222.04 / $277.55
| Professional | | $222.04 | $222.04 | $277.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,217.55 / $3,217.55 / $3,217.55
| Facility | | $3,217.55 | $3,217.55 | $3,217.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.00 / $710.04 / $710.04
| Professional | | $209.00 | $710.04 | $710.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $124.69 / $161.60 / $227.22
| Facility | | $124.69 | $161.60 | $227.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $124.69 / $218.00 / $238.63
| Professional | | $124.69 | $218.00 | $238.63 |