- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $448.76 / $524.41 / $845.85
| Facility | | $448.76 | $524.41 | $845.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $338.54 / $546.01 / $712.97
| Professional | | $338.54 | $546.01 | $712.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $268.00 / $1,692.26 / $1,692.26
| Professional | | $268.00 | $1,692.26 | $1,692.26 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $55.00 / $70.00
| Professional | | $50.00 | $55.00 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $6,857.30 / $6,857.30 / $6,857.30
| Facility | | $6,857.30 | $6,857.30 | $6,857.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $678.75 / $1,692.26 / $1,692.26
| Professional | | $678.75 | $1,692.26 | $1,692.26 |