- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $137.47 / $137.47 / $1,527.60
| Facility | | $137.47 | $137.47 | $1,527.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $137.47 / $137.47 / $718.55
| Professional | | $137.47 | $137.47 | $718.55 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $0.95 / $1.00 / $1.00
| Facility | | $0.95 | $1.00 | $1.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1.00 / $1.00 / $1.00
| Professional | | $1.00 | $1.00 | $1.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.00 / $165.00 / $165.00
| Professional | | $165.00 | $165.00 | $165.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $137.47 / $232.32 / $2,929.00
| Facility | | $137.47 | $232.32 | $2,929.00 |