- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $230.38 / $230.38 / $287.98
| Professional | | $230.38 | $230.38 | $287.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $113.81 / $140.81 / $1,821.49
| Facility | | $113.81 | $140.81 | $1,821.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $142.00 / $5,272.00 / $5,272.00
| Professional | | $142.00 | $5,272.00 | $5,272.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $78.13 / $78.13 / $142.00
| Facility | | $78.13 | $78.13 | $142.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $78.13 / $136.03 / $1,467.00
| Professional | | $78.13 | $136.03 | $1,467.00 |