- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $493.03 / $712.21 / $1,733.68
| Professional | | $493.03 | $712.21 | $1,733.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $1,634.50 / $5,000.00
| Facility | | $55.00 | $1,634.50 | $5,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,127.76 / $4,127.76 / $4,127.76
| Professional | | $4,127.76 | $4,127.76 | $4,127.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $458.99 / $570.32 / $912.18
| Facility | | $458.99 | $570.32 | $912.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $615.00 / $615.00 / $615.00
| Professional | | $615.00 | $615.00 | $615.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $458.99 / $572.65 / $912.18
| Facility | | $458.99 | $572.65 | $912.18 |