- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.73 / $217.50 / $929.84
| Professional | | $118.73 | $217.50 | $929.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $966.36 / $1,156.55 / $2,216.89
| Facility | | $966.36 | $1,156.55 | $2,216.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $242.05 / $242.05 / $1,035.40
| Facility | | $242.05 | $242.05 | $1,035.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.42 / $233.44 / $611.75
| Professional | | $86.42 | $233.44 | $611.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $242.05 / $242.05 / $1,035.40
| Facility | | $242.05 | $242.05 | $1,035.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.42 / $233.44 / $611.75
| Professional | | $86.42 | $233.44 | $611.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.24 / $200.00 / $334.11
| Professional | | $90.24 | $200.00 | $334.11 |