- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $195.29 / $195.29 / $789.56
| Facility | | $195.29 | $195.29 | $789.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $9.55 / $195.29 / $929.84
| Professional | | $9.55 | $195.29 | $929.84 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $195.29 / $364.83 / $606.41
| Facility | | $195.29 | $364.83 | $606.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,335.22 / $3,335.22 / $3,335.22
| Professional | | $3,335.22 | $3,335.22 | $3,335.22 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $30.00
| Professional | | $30.00 | $30.00 | $30.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $177.56 / $1,066.26 / $1,862.77
| Professional | | $177.56 | $1,066.26 | $1,862.77 |