- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $123.52 / $157.80 / $255.64
| Professional | | $123.52 | $157.80 | $255.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $974.00 / $974.00 / $974.00
| Facility | | $974.00 | $974.00 | $974.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $252.00 / $392.00 / $631.00
| Professional | | $252.00 | $392.00 | $631.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.34 / $277.27 / $498.14
| Professional | | $165.34 | $277.27 | $498.14 |
- 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
- $267.83 / $381.00 / $592.23
| Professional | | $267.83 | $381.00 | $592.23 |