- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.70 / $351.75 / $773.06
| Professional | | $164.70 | $351.75 | $773.06 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $420.32 / $11,500.00 / $12,000.00
| Facility | | $420.32 | $11,500.00 | $12,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,184.94 / $1,314.24 / $1,314.24
| Professional | | $1,184.94 | $1,314.24 | $1,314.24 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $185.27 / $234.79 / $319.52
| Facility | | $185.27 | $234.79 | $319.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.80 / $245.80 / $245.80
| Professional | | $245.80 | $245.80 | $245.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $185.27 / $235.53 / $319.52
| Facility | | $185.27 | $235.53 | $319.52 |