- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $197.29 / $241.24 / $301.55
| Professional | | $197.29 | $241.24 | $301.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $166.02 / $227.90 / $306.81
| Facility | | $166.02 | $227.90 | $306.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $921.00 / $921.00 / $921.00
| Professional | | $921.00 | $921.00 | $921.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $375.00 / $375.00 / $375.00
| Facility | | $375.00 | $375.00 | $375.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $163.00 / $195.00 / $351.31
| Professional | | $163.00 | $195.00 | $351.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $120.76 / $120.76 / $120.76
| Professional | | $120.76 | $120.76 | $120.76 |