- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.01 / $142.78 / $142.78
| Professional | | $120.01 | $142.78 | $142.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $773.60 / $773.60 / $773.60
| Facility | | $773.60 | $773.60 | $773.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,858.45 / $1,858.45 / $2,127.58
| Facility | | $1,858.45 | $1,858.45 | $2,127.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.66 / $185.17 / $509.21
| Professional | | $133.66 | $185.17 | $509.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,858.45 / $1,858.45 / $2,127.58
| Facility | | $1,858.45 | $1,858.45 | $2,127.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $133.66 / $196.04 / $509.21
| Professional | | $133.66 | $196.04 | $509.21 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.69 / $238.24 / $541.66
| Professional | | $116.69 | $238.24 | $541.66 |