- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $624.78 / $1,163.29 / $2,265.37
| Professional | | $624.78 | $1,163.29 | $2,265.37 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $758.35 / $11,500.00 / $12,000.00
| Facility | | $758.35 | $11,500.00 | $12,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,122.00 / $2,324.05 / $2,324.05
| Professional | | $2,122.00 | $2,324.05 | $2,324.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $312.98 / $546.26 / $900.00
| Facility | | $312.98 | $546.26 | $900.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5.00 / $651.29 / $1,114.50
| Professional | | $5.00 | $651.29 | $1,114.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $314.87 / $551.51 / $918.71
| Facility | | $314.87 | $551.51 | $918.71 |