- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $254.87 / $313.20 / $1,652.62
| Facility | | $254.87 | $313.20 | $1,652.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $85.00 / $100.00 / $100.00
| Professional | | $85.00 | $100.00 | $100.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $425.36 / $626.66 / $626.66
| Facility | | $425.36 | $626.66 | $626.66 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $332.00 / $760.00 / $1,300.00
| Facility | | $332.00 | $760.00 | $1,300.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,415.11 / $1,415.11 / $1,415.11
| Professional | | $1,415.11 | $1,415.11 | $1,415.11 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $247.00 / $760.00 / $1,351.00
| Facility | | $247.00 | $760.00 | $1,351.00 |