- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $836.55 / $836.55 / $836.55
| Facility | | $836.55 | $836.55 | $836.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $35.92 / $55.78 / $241.00
| Professional | | $35.92 | $55.78 | $241.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $461.55 / $461.55 / $591.11
| Facility | | $461.55 | $461.55 | $591.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.11 / $138.77 / $217.60
| Professional | | $138.11 | $138.77 | $217.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.65 / $70.75 / $105.92
| Professional | | $51.65 | $70.75 | $105.92 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.65 / $70.75 / $105.88
| Professional | | $51.65 | $70.75 | $105.88 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $67.02 / $74.30 / $245.21
| Professional | | $67.02 | $74.30 | $245.21 |