- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $508.74 / $508.74 / $508.74
| Facility | | $508.74 | $508.74 | $508.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.74 / $146.74 / $508.74
| Professional | | $146.74 | $146.74 | $508.74 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $108.72 / $108.72 / $132.40
| Professional | | $108.72 | $108.72 | $132.40 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $259.57 / $259.57 / $259.57
| Professional | | $259.57 | $259.57 | $259.57 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $146.74 / $508.74 / $763.11
| Facility | | $146.74 | $508.74 | $763.11 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $155.00 / $155.00 / $329.00
| Professional | | $155.00 | $155.00 | $329.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $249.47 / $249.47 / $249.47
| Professional | | $249.47 | $249.47 | $249.47 |