- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $407.38 / $407.38 / $512.86
| Professional | | $407.38 | $407.38 | $512.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,606.93 / $19,498.45 / $19,498.45
| Facility | | $6,606.93 | $19,498.45 | $19,498.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,479.11 / $1,479.11 / $1,479.11
| Professional | | $1,479.11 | $1,479.11 | $1,479.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.88 / $316.23 / $457.09
| Facility | | $239.88 | $316.23 | $457.09 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6.03 / $416.87 / $501.19
| Professional | | $6.03 | $416.87 | $501.19 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.88 / $323.59 / $467.74
| Facility | | $239.88 | $323.59 | $467.74 |