- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.37 / $239.37 / $1,469.60
| Facility | | $239.37 | $239.37 | $1,469.60 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $239.37 / $239.37 / $659.93
| Professional | | $239.37 | $239.37 | $659.93 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $0.02 / $0.02 / $0.02
| Professional | | $0.02 | $0.02 | $0.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $239.37 / $253.73 / $404.54
| Facility | | $239.37 | $253.73 | $404.54 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $925.00 / $1,750.00
| Facility | | $100.00 | $925.00 | $1,750.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $100.00 / $925.00 / $1,750.00
| Professional | | $100.00 | $925.00 | $1,750.00 |