- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $368.46 / $368.46 / $411.50
| Facility | | $368.46 | $368.46 | $411.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $368.46 / $368.46 / $368.46
| Professional | | $368.46 | $368.46 | $368.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $609.00 / $820.18 / $1,746.22
| Facility | | $609.00 | $820.18 | $1,746.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $48.39 / $63.26 / $73.77
| Professional | | $48.39 | $63.26 | $73.77 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $8,778.27 / $25,468.04 / $49,514.96
| Facility | | $8,778.27 | $25,468.04 | $49,514.96 |