- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $175.28 / $175.28 / $175.28
| Facility | | $175.28 | $175.28 | $175.28 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $175.28 / $175.28 / $175.28
| Professional | | $175.28 | $175.28 | $175.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $681.00 / $681.00 / $681.00
| Facility | | $681.00 | $681.00 | $681.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $681.00 / $681.00 / $681.00
| Professional | | $681.00 | $681.00 | $681.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $527.40 / $527.40 / $527.40
| Professional | | $527.40 | $527.40 | $527.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $17.00 / $21.25 / $50.00
| Professional | | $17.00 | $21.25 | $50.00 |