- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $164.70 / $210.23 / $255.35
| Professional | | $164.70 | $210.23 | $255.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $210.23 / $222.84 / $326.85
| Facility | | $210.23 | $222.84 | $326.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $3,900.00
| Professional | | $30.00 | $30.00 | $3,900.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,559.73 / $3,612.83 / $4,302.32
| Facility | | $2,559.73 | $3,612.83 | $4,302.32 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $419.70 / $446.76 / $470.01
| Professional | | $419.70 | $446.76 | $470.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $196.74 / $258.39 / $462.40
| Professional | | $196.74 | $258.39 | $462.40 |