- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $360.00 / $495.73 / $519.54
| Professional | | $360.00 | $495.73 | $519.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $612.50 / $709.12 / $3,195.24
| Facility | | $612.50 | $709.12 | $3,195.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.45 / $109.45 / $136.81
| Professional | | $109.45 | $109.45 | $136.81 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $519.54 / $519.54 / $665.02
| Facility | | $519.54 | $519.54 | $665.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.00 / $55.00 / $78.00
| Professional | | $55.00 | $55.00 | $78.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $978.23 / $1,933.52 / $2,605.34
| Facility | | $978.23 | $1,933.52 | $2,605.34 |