- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $206.60 / $242.10 / $367.88
| Professional | | $206.60 | $242.10 | $367.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,167.00 / $1,167.00 / $1,437.00
| Facility | | $1,167.00 | $1,167.00 | $1,437.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $59.12 / $70.23 / $124.49
| Professional | | $59.12 | $70.23 | $124.49 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.20 / $106.20 / $106.20
| Professional | | $106.20 | $106.20 | $106.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.83 / $0.83 / $350.00
| Professional | | $0.83 | $0.83 | $350.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.83 / $0.83 / $0.83
| Professional | | $0.83 | $0.83 | $0.83 |