- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.96 / $204.96 / $3,509.59
| Facility | | $204.96 | $204.96 | $3,509.59 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.96 / $204.96 / $207.00
| Professional | | $204.96 | $204.96 | $207.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $204.96 / $634.27 / $879.38
| Facility | | $204.96 | $634.27 | $879.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.96 / $204.96 / $232.02
| Professional | | $204.96 | $204.96 | $232.02 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $193.35 / $204.95 / $338.36
| Professional | | $193.35 | $204.95 | $338.36 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,165.00 / $13,785.00 / $13,785.00
| Facility | | $1,165.00 | $13,785.00 | $13,785.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $262.93 / $335.86 / $456.23
| Professional | | $262.93 | $335.86 | $456.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $204.96 / $204.96 / $221.60
| Professional | | $204.96 | $204.96 | $221.60 |