- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $139.87 / $208.42 / $284.30
| Professional | | $139.87 | $208.42 | $284.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $214.01 / $1,024.71 / $1,024.71
| Facility | | $214.01 | $1,024.71 | $1,024.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,138.00 / $1,138.00 / $1,138.00
| Professional | | $1,138.00 | $1,138.00 | $1,138.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $124.39 / $207.06 / $306.83
| Facility | | $124.39 | $207.06 | $306.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $185.20 / $202.40 / $309.10
| Professional | | $185.20 | $202.40 | $309.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $124.52 / $209.80 / $306.83
| Facility | | $124.52 | $209.80 | $306.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.32 / $116.32 / $116.32
| Professional | | $116.32 | $116.32 | $116.32 |