- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $165.70 / $165.70 / $259.24
| Facility | | $165.70 | $165.70 | $259.24 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.70 / $165.70 / $174.80
| Professional | | $165.70 | $165.70 | $174.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $340.89 / $499.92 / $927.06
| Facility | | $340.89 | $499.92 | $927.06 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $300.00 / $300.00
| Professional | | $300.00 | $300.00 | $300.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $306.00 / $306.00 / $306.00
| Facility | | $306.00 | $306.00 | $306.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $306.00 / $306.00 / $306.00
| Professional | | $306.00 | $306.00 | $306.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $300.00 / $300.00 / $331.20
| Professional | | $300.00 | $300.00 | $331.20 |