- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $382.07 / $446.48 / $684.92
| Facility | | $382.07 | $446.48 | $684.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.59 / $304.89 / $574.67
| Professional | | $170.59 | $304.89 | $574.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,017.00 / $1,017.00 / $1,017.00
| Professional | | $1,017.00 | $1,017.00 | $1,017.00 |
- 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
- $312.39 / $312.39 / $312.39
| Facility | | $312.39 | $312.39 | $312.39 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $220.55 / $1,017.00 / $1,017.00
| Professional | | $220.55 | $1,017.00 | $1,017.00 |