- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.77 / $315.91 / $1,757.42
| Professional | | $183.77 | $315.91 | $1,757.42 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.44 / $270.80 / $471.90
| Facility | | $57.44 | $270.80 | $471.90 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $364.00 / $364.00 / $364.00
| Professional | | $364.00 | $364.00 | $364.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $282.60 / $282.60 / $304.80
| Professional | | $282.60 | $282.60 | $304.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $124.73 / $445.41
| Facility | | $55.00 | $124.73 | $445.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $591.10 / $1,108.72 / $1,209.40
| Professional | | $591.10 | $1,108.72 | $1,209.40 |