- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $536.45
| Facility | | $30.00 | $30.00 | $536.45 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $385.10
| Professional | | $30.00 | $30.00 | $385.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.00 / $300.00 / $505.88
| Professional | | $180.00 | $300.00 | $505.88 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.00 / $1,950.00 / $3,000.00
| Facility | | $30.00 | $1,950.00 | $3,000.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $180.00 / $180.00 / $406.00
| Professional | | $180.00 | $180.00 | $406.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.00 / $65.00 / $85.00
| Professional | | $43.00 | $65.00 | $85.00 |