- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.92 / $375.71 / $890.26
| Professional | | $184.92 | $375.71 | $890.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $253.04 / $11,500.00 / $12,000.00
| Facility | | $253.04 | $11,500.00 | $12,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,182.00 / $1,587.96 / $1,587.96
| Professional | | $1,182.00 | $1,587.96 | $1,587.96 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.15 / $285.86 / $417.88
| Facility | | $114.15 | $285.86 | $417.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $278.50 / $278.50 / $278.50
| Professional | | $278.50 | $278.50 | $278.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $114.15 / $285.86 / $417.88
| Facility | | $114.15 | $285.86 | $417.88 |