- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $41.50 / $262.39
| Professional | | $30.00 | $41.50 | $262.39 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $415.75 / $546.83 / $1,057.75
| Facility | | $415.75 | $546.83 | $1,057.75 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $196.44 / $1,242.00 / $4,406.00
| Facility | | $196.44 | $1,242.00 | $4,406.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $33.50 / $33.50 / $33.50
| Professional | | $33.50 | $33.50 | $33.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,031.00 / $1,775.00 / $4,406.00
| Facility | | $1,031.00 | $1,775.00 | $4,406.00 |