- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $441.00 / $777.60 / $777.60
| Facility | | $441.00 | $777.60 | $777.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $50.00 / $777.60
| Professional | | $30.00 | $50.00 | $777.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $36.52 / $142.03 / $340.87
| Facility | | $36.52 | $142.03 | $340.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.23 / $267.83 / $632.40
| Professional | | $79.23 | $267.83 | $632.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $336.00 / $480.00 / $688.00
| Professional | | $336.00 | $480.00 | $688.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.00 / $53.00 / $70.00
| Professional | | $44.00 | $53.00 | $70.00 |