- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $173.78 / $208.93
| Professional | | $173.78 | $173.78 | $208.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $302.00 / $302.00 / $302.00
| Professional | | $302.00 | $302.00 | $302.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,370.32 / $6,309.57 / $8,511.38
| Facility | | $5,370.32 | $6,309.57 | $8,511.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $173.78 / $173.78
| Professional | | $173.78 | $173.78 | $173.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.78 / $173.78 / $173.78
| Facility | | $173.78 | $173.78 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $173.78 / $173.78 / $186.21
| Professional | | $173.78 | $173.78 | $186.21 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.96 / $173.78 / $173.78
| Facility | | $165.96 | $173.78 | $173.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.54 / $173.78 / $199.53
| Professional | | $144.54 | $173.78 | $199.53 |