- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $183.77 / $232.71 / $1,294.55
| Professional | | $183.77 | $232.71 | $1,294.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $137.33 / $445.41
| Facility | | $55.00 | $137.33 | $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 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $57.56 / $247.65 / $421.01
| Facility | | $57.56 | $247.65 | $421.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $304.80 / $514.29 / $623.60
| Professional | | $304.80 | $514.29 | $623.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $60.88 / $247.65 / $421.01
| Facility | | $60.88 | $247.65 | $421.01 |