- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $686.07 / $1,131.60 / $1,632.41
| Professional | | $686.07 | $1,131.60 | $1,632.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $212.41 / $380.84 / $628.61
| Facility | | $212.41 | $380.84 | $628.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $475.00 / $475.00 / $475.00
| Professional | | $475.00 | $475.00 | $475.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $269.70 / $321.30 / $720.10
| Professional | | $269.70 | $321.30 | $720.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $454.39 / $2,543.25 / $12,000.00
| Facility | | $454.39 | $2,543.25 | $12,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,350.00 / $1,460.17 / $1,460.17
| Professional | | $1,350.00 | $1,460.17 | $1,460.17 |