- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $173.97 / $217.46 / $217.46
| Facility | | $173.97 | $217.46 | $217.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $217.46 / $217.46 / $217.46
| Professional | | $217.46 | $217.46 | $217.46 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $622.00 / $622.00 / $622.00
| Facility | | $622.00 | $622.00 | $622.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $622.00 / $622.00 / $622.00
| Professional | | $622.00 | $622.00 | $622.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $42.37 / $94.39 / $166.64
| Facility | | $42.37 | $94.39 | $166.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $20.00 / $20.00
| Professional | | $17.00 | $20.00 | $20.00 |