- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $940.22 / $1,034.64 / $1,293.31
| Professional | | $940.22 | $1,034.64 | $1,293.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $743.00 / $5,414.80 / $12,000.00
| Facility | | $743.00 | $5,414.80 | $12,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $487.00 / $2,058.35 / $2,058.35
| Professional | | $487.00 | $2,058.35 | $2,058.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $532.00 / $689.47 / $743.00
| Facility | | $532.00 | $689.47 | $743.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $522.15 / $689.47 / $909.73
| Professional | | $522.15 | $689.47 | $909.73 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.00 / $660.70 / $1,073.80
| Professional | | $5.00 | $660.70 | $1,073.80 |