- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $240.53 / $369.17 / $750.05
| Professional | | $240.53 | $369.17 | $750.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $55.00 / $1,300.00
| Facility | | $55.00 | $55.00 | $1,300.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,286.00 / $1,306.17 / $1,306.17
| Professional | | $1,286.00 | $1,306.17 | $1,306.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.38 / $242.36 / $346.10
| Facility | | $162.38 | $242.36 | $346.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.30 / $217.30 / $217.30
| Professional | | $217.30 | $217.30 | $217.30 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $162.38 / $242.36 / $346.10
| Facility | | $162.38 | $242.36 | $346.10 |