- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $194.98 / $295.12
| Professional | | $151.36 | $194.98 | $295.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $794.33 / $1,000.00 / $1,000.00
| Facility | | $794.33 | $1,000.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $107.15 / $204.17 / $363.08
| Professional | | $107.15 | $204.17 | $363.08 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $181.97 / $275.42 / $407.38
| Professional | | $181.97 | $275.42 | $407.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.82 / $173.78 / $309.03
| Professional | | $128.82 | $173.78 | $309.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.49 / $204.17 / $398.11
| Professional | | $158.49 | $204.17 | $398.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $151.36 / $251.19 / $416.87
| Professional | | $151.36 | $251.19 | $416.87 |