- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $564.01 / $679.08 / $1,104.53
| Professional | | $564.01 | $679.08 | $1,104.53 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $180.16 / $252.30 / $585.14
| Facility | | $180.16 | $252.30 | $585.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $243.00 / $243.00 / $243.00
| Professional | | $243.00 | $243.00 | $243.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.60 / $214.70 / $340.20
| Professional | | $181.60 | $214.70 | $340.20 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $477.31 / $7,738.55 / $12,000.00
| Facility | | $477.31 | $7,738.55 | $12,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $808.85 / $808.85 / $808.85
| Professional | | $808.85 | $808.85 | $808.85 |