- 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 / $972.00 / $972.00
| Facility | | $214.01 | $972.00 | $972.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,381.00 / $1,381.00 / $1,381.00
| Professional | | $1,381.00 | $1,381.00 | $1,381.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $124.39 / $207.06 / $367.77
| Facility | | $124.39 | $207.06 | $367.77 |
- 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
- $124.93 / $209.80 / $367.77
| Facility | | $124.93 | $209.80 | $367.77 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.70 / $116.70 / $116.70
| Professional | | $116.70 | $116.70 | $116.70 |