- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $149.22 / $149.22 / $576.03
| Facility | | $149.22 | $149.22 | $576.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $149.22 / $149.22 / $149.22
| Professional | | $149.22 | $149.22 | $149.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58.38 / $270.48 / $497.44
| Facility | | $58.38 | $270.48 | $497.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.56 / $158.56 / $158.56
| Professional | | $158.56 | $158.56 | $158.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $158.56 / $158.56 / $158.56
| Facility | | $158.56 | $158.56 | $158.56 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $158.56 / $158.56 / $158.56
| Professional | | $158.56 | $158.56 | $158.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $59.14 / $149.22 / $221.41
| Facility | | $59.14 | $149.22 | $221.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,252.00 / $2,252.00 / $2,252.00
| Professional | | $2,252.00 | $2,252.00 | $2,252.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.44 / $155.44 / $155.44
| Professional | | $155.44 | $155.44 | $155.44 |