- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $307.17 / $382.04 / $616.03
| Professional | | $307.17 | $382.04 | $616.03 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $328.08 / $970.20 / $970.20
| Facility | | $328.08 | $970.20 | $970.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,842.00 / $1,842.00 / $1,842.00
| Professional | | $1,842.00 | $1,842.00 | $1,842.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.63 / $245.16 / $343.59
| Facility | | $116.63 | $245.16 | $343.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $245.60 / $264.10 / $333.70
| Professional | | $245.60 | $264.10 | $333.70 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $149.21 / $246.50 / $343.59
| Facility | | $149.21 | $246.50 | $343.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.49 / $206.49 / $206.49
| Professional | | $206.49 | $206.49 | $206.49 |