- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.18 / $240.15 / $412.92
| Professional | | $172.18 | $240.15 | $412.92 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $220.55 / $260.00 / $12,000.00
| Facility | | $220.55 | $260.00 | $12,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.25 / $396.00 / $1,017.00
| Professional | | $146.25 | $396.00 | $1,017.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.75 / $260.00 / $260.00
| Facility | | $158.75 | $260.00 | $260.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.97 / $251.64 / $282.63
| Professional | | $144.97 | $251.64 | $282.63 |