- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.42 / $304.62 / $760.00
| Professional | | $204.42 | $304.62 | $760.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $109.03 / $176.36 / $308.04
| Facility | | $109.03 | $176.36 | $308.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.00 / $144.00 / $195.00
| Professional | | $51.00 | $144.00 | $195.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $129.50 / $146.60 / $291.70
| Professional | | $129.50 | $146.60 | $291.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $297.07 / $446.55 / $510.28
| Facility | | $297.07 | $446.55 | $510.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,890.00 / $1,890.00 / $1,890.00
| Professional | | $1,890.00 | $1,890.00 | $1,890.00 |