- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $161.40 / $203.06 / $790.00
| Professional | | $161.40 | $203.06 | $790.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $522.29 / $705.42 / $835.14
| Facility | | $522.29 | $705.42 | $835.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $224.73 / $264.39 / $334.07
| Professional | | $224.73 | $264.39 | $334.07 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $211.27 / $211.27 / $211.27
| Facility | | $211.27 | $211.27 | $211.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $117.00 / $165.48 / $211.27
| Professional | | $117.00 | $165.48 | $211.27 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $144.30 / $197.46 / $307.16
| Professional | | $144.30 | $197.46 | $307.16 |