- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $109.66 / $280.62 / $645.23
| Professional | | $109.66 | $280.62 | $645.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $252.05 / $11,500.00 / $12,000.00
| Facility | | $252.05 | $11,500.00 | $12,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,021.00 / $1,149.42 / $1,149.42
| Professional | | $1,021.00 | $1,149.42 | $1,149.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.87 / $242.92 / $365.40
| Facility | | $107.87 | $242.92 | $365.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $244.50 / $244.50 / $244.50
| Professional | | $244.50 | $244.50 | $244.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $107.87 / $242.92 / $365.40
| Facility | | $107.87 | $242.92 | $365.40 |