- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $182.03 / $212.71 / $326.31
| Facility | | $182.03 | $212.71 | $326.31 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $128.51 / $192.65 / $231.01
| Professional | | $128.51 | $192.65 | $231.01 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.00 / $500.00 / $500.00
| Professional | | $500.00 | $500.00 | $500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $58.40 / $70.00
| Professional | | $50.00 | $58.40 | $70.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $341.79 / $341.79 / $341.79
| Facility | | $341.79 | $341.79 | $341.79 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.63 / $500.00 / $500.00
| Professional | | $239.63 | $500.00 | $500.00 |