- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.66 / $220.54 / $220.54
| Professional | | $162.66 | $220.54 | $220.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,309.83 / $1,309.83 / $1,309.83
| Facility | | $1,309.83 | $1,309.83 | $1,309.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,175.77 / $3,175.77 / $7,473.86
| Facility | | $3,175.77 | $3,175.77 | $7,473.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.55 / $339.81 / $659.22
| Professional | | $203.55 | $339.81 | $659.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,175.77 / $3,175.77 / $7,473.86
| Facility | | $3,175.77 | $3,175.77 | $7,473.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $203.55 / $353.38 / $659.22
| Professional | | $203.55 | $353.38 | $659.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $201.52 / $360.03 / $701.24
| Professional | | $201.52 | $360.03 | $701.24 |