- 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
- $318.75 / $318.75 / $425.00
| Professional | | $318.75 | $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
- $310.76 / $590.41 / $642.16
| Professional | | $310.76 | $590.41 | $642.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,360.46 / $1,360.46 / $1,360.46
| Facility | | $1,360.46 | $1,360.46 | $1,360.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,178.40 / $1,178.40 / $1,178.40
| Professional | | $1,178.40 | $1,178.40 | $1,178.40 |