- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $506.01 / $506.01 / $506.01
| Facility | | $506.01 | $506.01 | $506.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $506.01 / $506.01 / $506.01
| Professional | | $506.01 | $506.01 | $506.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $255.84 / $337.55 / $932.04
| Professional | | $255.84 | $337.55 | $932.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $48,999.51 / $52,499.48 / $61,249.39
| Facility | | $48,999.51 | $52,499.48 | $61,249.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $314.01 / $355.10 / $480.69
| Professional | | $314.01 | $355.10 | $480.69 |