- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $145.91 / $182.64 / $297.63
| Professional | | $145.91 | $182.64 | $297.63 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,385.60 / $1,385.60 / $1,385.60
| Facility | | $1,385.60 | $1,385.60 | $1,385.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $275.00 / $415.00 / $642.00
| Professional | | $275.00 | $415.00 | $642.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $190.47 / $315.25 / $603.16
| Professional | | $190.47 | $315.25 | $603.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $788.00 / $788.00 / $3,328.00
| Facility | | $788.00 | $788.00 | $3,328.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.21 / $424.81 / $671.28
| Professional | | $224.21 | $424.81 | $671.28 |