- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.06 / $284.33 / $284.33
| Professional | | $170.06 | $284.33 | $284.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,648.73 / $1,648.73 / $1,648.73
| Facility | | $1,648.73 | $1,648.73 | $1,648.73 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,473.86 / $7,473.86 / $7,473.86
| Facility | | $7,473.86 | $7,473.86 | $7,473.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $248.77 / $399.42 / $718.57
| Professional | | $248.77 | $399.42 | $718.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,473.86 / $7,473.86 / $7,473.86
| Facility | | $7,473.86 | $7,473.86 | $7,473.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.48 / $399.42 / $718.57
| Professional | | $252.48 | $399.42 | $718.57 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $182.77 / $392.44 / $764.37
| Professional | | $182.77 | $392.44 | $764.37 |