- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $312.75 / $382.42 / $478.03
| Professional | | $312.75 | $382.42 | $478.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $181.21 / $194.77 / $1,783.26
| Facility | | $181.21 | $194.77 | $1,783.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,807.00 / $5,807.00 / $5,807.00
| Professional | | $5,807.00 | $5,807.00 | $5,807.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $214.53 / $228.00 / $228.00
| Facility | | $214.53 | $228.00 | $228.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $160.41 / $224.74 / $1,710.00
| Professional | | $160.41 | $224.74 | $1,710.00 |