- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.09 / $204.98 / $265.18
| Professional | | $162.09 | $204.98 | $265.18 |
- 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
- $312.00 / $472.00 / $740.00
| Professional | | $312.00 | $472.00 | $740.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $219.19 / $362.48 / $687.98
| Professional | | $219.19 | $362.48 | $687.98 |
- 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
- $273.60 / $502.90 / $824.18
| Professional | | $273.60 | $502.90 | $824.18 |