- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.43 / $315.43 / $455.00
| Professional | | $315.43 | $315.43 | $455.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $48.24 / $53.77 / $201.36
| Facility | | $48.24 | $53.77 | $201.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.48 / $2.48 / $3.10
| Professional | | $2.48 | $2.48 | $3.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $315.43 / $315.43 / $403.75
| Facility | | $315.43 | $315.43 | $403.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.00 / $55.00 / $78.00
| Professional | | $55.00 | $55.00 | $78.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.68 / $136.88 / $167.22
| Facility | | $97.68 | $136.88 | $167.22 |