- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $768.95 / $768.95 / $16,467.00
| Facility | | $768.95 | $768.95 | $16,467.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,493.08 / $3,696.77 / $3,696.77
| Professional | | $3,493.08 | $3,696.77 | $3,696.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $672.66 / $1,287.34 / $2,180.11
| Facility | | $672.66 | $1,287.34 | $2,180.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $55.00
| Professional | | $30.00 | $30.00 | $55.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $461.00 / $3,866.00 / $6,584.00
| Facility | | $461.00 | $3,866.00 | $6,584.00 |