- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $548.86 / $548.86 / $548.86
| Facility | | $548.86 | $548.86 | $548.86 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $548.86 / $548.86 / $548.86
| Professional | | $548.86 | $548.86 | $548.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.47 / $327.16 / $809.07
| Facility | | $138.47 | $327.16 | $809.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $140.63 / $173.10 / $408.94
| Professional | | $140.63 | $173.10 | $408.94 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $548.86 / $603.75 / $1,161.36
| Facility | | $548.86 | $603.75 | $1,161.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,800.00 / $4,800.00 / $4,800.00
| Professional | | $4,800.00 | $4,800.00 | $4,800.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,800.00 / $4,800.00 / $4,800.00
| Professional | | $4,800.00 | $4,800.00 | $4,800.00 |