- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.24 / $361.80 / $735.08
| Professional | | $249.24 | $361.80 | $735.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $55.00 / $55.00 / $26,050.70
| Facility | | $55.00 | $55.00 | $26,050.70 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.00 / $8,263.84 / $8,263.84
| Professional | | $1,122.00 | $8,263.84 | $8,263.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $132.78 / $206.65 / $290.07
| Facility | | $132.78 | $206.65 | $290.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.50 / $206.50 / $206.50
| Professional | | $206.50 | $206.50 | $206.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $132.78 / $206.65 / $290.07
| Facility | | $132.78 | $206.65 | $290.07 |