- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.30 / $203.23 / $254.04
| Professional | | $175.30 | $203.23 | $254.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $189.18 / $238.28 / $538.66
| Facility | | $189.18 | $238.28 | $538.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $209.87 / $693.00 / $693.00
| Professional | | $209.87 | $693.00 | $693.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $210.00 / $210.00 / $210.00
| Facility | | $210.00 | $210.00 | $210.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $187.29 / $209.87 / $264.00
| Professional | | $187.29 | $209.87 | $264.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $294.60 / $294.60 / $294.60
| Professional | | $294.60 | $294.60 | $294.60 |