- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $189.84 / $230.39 / $966.00
| Professional | | $189.84 | $230.39 | $966.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,702.93 / $1,702.93 / $2,115.13
| Facility | | $1,702.93 | $1,702.93 | $2,115.13 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $213.96 / $315.70 / $772.86
| Professional | | $213.96 | $315.70 | $772.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.00 / $315.52 / $772.86
| Professional | | $240.00 | $315.52 | $772.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $257.14 / $294.00 / $948.60
| Professional | | $257.14 | $294.00 | $948.60 |