- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $318.75 / $738.00 / $900.00
| Facility | | $318.75 | $738.00 | $900.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $237.07 / $318.75 / $425.00
| Professional | | $237.07 | $318.75 | $425.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $510.00 / $706.00 / $1,000.00
| Facility | | $510.00 | $706.00 | $1,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $453.51 / $861.65 / $937.25
| Professional | | $453.51 | $861.65 | $937.25 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $133.62 / $133.62 / $133.62
| Facility | | $133.62 | $133.62 | $133.62 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $889.64 / $889.64 / $889.64
| Professional | | $889.64 | $889.64 | $889.64 |