- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $207.70 / $259.63 / $505.59
| Professional | | $207.70 | $259.63 | $505.59 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $219.77 / $11,500.00 / $12,000.00
| Facility | | $219.77 | $11,500.00 | $12,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $478.52 / $478.52 / $492.17
| Professional | | $478.52 | $478.52 | $492.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $99.31 / $131.65 / $173.80
| Facility | | $99.31 | $131.65 | $173.80 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.10 / $138.10 / $138.10
| Professional | | $138.10 | $138.10 | $138.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $99.31 / $131.84 / $173.80
| Facility | | $99.31 | $131.84 | $173.80 |