- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $330.76 / $330.76 / $330.76
| Professional | | $330.76 | $330.76 | $330.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $21,399.81 / $25,969.67 / $34,937.53
| Facility | | $21,399.81 | $25,969.67 | $34,937.53 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $195.00 / $195.00 / $195.00
| Professional | | $195.00 | $195.00 | $195.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $206.70 / $206.70 / $206.70
| Facility | | $206.70 | $206.70 | $206.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.70 / $206.70 / $385.37
| Professional | | $206.70 | $206.70 | $385.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $234.00 / $234.00 / $234.00
| Professional | | $234.00 | $234.00 | $234.00 |