- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $294.12 / $685.65 / $1,343.02
| Facility | | $294.12 | $685.65 | $1,343.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $211.71 / $317.60 / $317.60
| Professional | | $211.71 | $317.60 | $317.60 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $105.00 / $105.00 / $105.00
| Facility | | $105.00 | $105.00 | $105.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $105.00 / $105.00 / $105.00
| Professional | | $105.00 | $105.00 | $105.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $116.76 / $116.76 / $116.76
| Professional | | $116.76 | $116.76 | $116.76 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $21.25 / $50.00
| Professional | | $17.00 | $21.25 | $50.00 |