- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $539.00 / $950.40 / $950.40
| Facility | | $539.00 | $950.40 | $950.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $50.00 / $950.40
| Professional | | $30.00 | $50.00 | $950.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $41.09 / $159.79 / $383.48
| Facility | | $41.09 | $159.79 | $383.48 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.40 / $301.31 / $711.45
| Professional | | $90.40 | $301.31 | $711.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $420.00 / $600.00 / $860.00
| Professional | | $420.00 | $600.00 | $860.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $56.00 / $73.00
| Professional | | $45.00 | $56.00 | $73.00 |