- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.22 / $570.91 / $6,019.65
| Facility | | $318.22 | $570.91 | $6,019.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $318.22 / $318.22 / $1,963.12
| Professional | | $318.22 | $318.22 | $1,963.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,133.69 / $2,043.76 / $2,780.60
| Facility | | $1,133.69 | $2,043.76 | $2,780.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,152.99 / $5,152.99 / $5,152.99
| Facility | | $5,152.99 | $5,152.99 | $5,152.99 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $673.84 / $673.84 / $673.84
| Professional | | $673.84 | $673.84 | $673.84 |