- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $218.76 / $273.45 / $273.45
| Facility | | $218.76 | $273.45 | $273.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $273.45 / $273.45 / $273.45
| Professional | | $273.45 | $273.45 | $273.45 |
- 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 / $203.01 / $319.43
| Facility | | $42.37 | $203.01 | $319.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $20.00 / $20.00
| Professional | | $17.00 | $20.00 | $20.00 |