- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $188.41 / $230.38 / $287.98
| Professional | | $188.41 | $230.38 | $287.98 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $108.77 / $117.44 / $1,618.91
| Facility | | $108.77 | $117.44 | $1,618.91 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $5,272.00 / $5,272.00 / $5,272.00
| Professional | | $5,272.00 | $5,272.00 | $5,272.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $128.75 / $142.00 / $142.00
| Facility | | $128.75 | $142.00 | $142.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $97.20 / $136.72 / $1,269.00
| Professional | | $97.20 | $136.72 | $1,269.00 |