- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $900.00 / $988.26 / $988.26
| Professional | | $900.00 | $988.26 | $988.26 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $139.91 / $161.38 / $634.67
| Facility | | $139.91 | $161.38 | $634.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $736.38 / $736.38 / $920.47
| Professional | | $736.38 | $736.38 | $920.47 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $988.26 / $988.26 / $1,264.97
| Facility | | $988.26 | $988.26 | $1,264.97 |
- 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
- $307.89 / $429.29 / $524.42
| Facility | | $307.89 | $429.29 | $524.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,560.00 / $1,560.00 / $1,560.00
| Professional | | $1,560.00 | $1,560.00 | $1,560.00 |