- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.49 / $625.61 / $1,218.31
| Professional | | $500.49 | $625.61 | $1,218.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,422.20 / $11,500.00 / $16,394.00
| Facility | | $1,422.20 | $11,500.00 | $16,394.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,635.00 / $3,635.00 / $3,635.00
| Professional | | $3,635.00 | $3,635.00 | $3,635.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $264.86 / $333.55 / $556.36
| Facility | | $264.86 | $333.55 | $556.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.50 / $306.50 / $306.50
| Professional | | $306.50 | $306.50 | $306.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $267.27 / $333.55 / $556.36
| Facility | | $267.27 | $333.55 | $556.36 |