- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $23.00 / $242.33 / $317.60
| Professional | | $23.00 | $242.33 | $317.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $815.98 / $856.35 / $1,588.13
| Facility | | $815.98 | $856.35 | $1,588.13 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,021.00 / $1,021.00 / $1,021.00
| Facility | | $1,021.00 | $1,021.00 | $1,021.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.76 / $116.76 / $178.12
| Professional | | $116.76 | $116.76 | $178.12 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,021.00 / $1,021.00 / $1,021.00
| Facility | | $1,021.00 | $1,021.00 | $1,021.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.76 / $116.76 / $178.12
| Professional | | $116.76 | $116.76 | $178.12 |