- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $475.25 / $475.25 / $594.05
| Professional | | $475.25 | $475.25 | $594.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $584.00 / $36,414.80
| Facility | | $55.00 | $584.00 | $36,414.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $443.16 / $620.00 / $3,329.10
| Professional | | $443.16 | $620.00 | $3,329.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $260.66 / $337.82 / $584.00
| Facility | | $260.66 | $337.82 | $584.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $267.29 / $535.00 / $620.00
| Professional | | $267.29 | $535.00 | $620.00 |