- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $157.33 / $192.37 / $240.47
| Professional | | $157.33 | $192.37 | $240.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $135.78 / $427.69 / $916.35
| Facility | | $135.78 | $427.69 | $916.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,984.00 / $2,984.00 / $2,984.00
| Professional | | $2,984.00 | $2,984.00 | $2,984.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $275.00 / $275.00 / $275.00
| Facility | | $275.00 | $275.00 | $275.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.04 / $276.66 / $600.00
| Professional | | $170.04 | $276.66 | $600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.64 / $144.47 / $382.01
| Professional | | $122.64 | $144.47 | $382.01 |