- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $383.11 / $491.52 / $491.52
| Professional | | $383.11 | $491.52 | $491.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $200.00 / $200.00 / $200.00
| Facility | | $200.00 | $200.00 | $200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $170.00 / $200.00 / $206.00
| Professional | | $170.00 | $200.00 | $206.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $200.00 / $200.00 / $200.00
| Facility | | $200.00 | $200.00 | $200.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $200.00 / $200.00 / $206.00
| Professional | | $200.00 | $200.00 | $206.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $289.14 / $569.14 / $722.84
| Professional | | $289.14 | $569.14 | $722.84 |