- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $302.67 / $302.67 / $302.67
| Facility | | $302.67 | $302.67 | $302.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $29.46 / $41.91 / $115.16
| Professional | | $29.46 | $41.91 | $115.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $65.00 / $78.00 / $170.00
| Professional | | $65.00 | $78.00 | $170.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.32 / $66.30 / $173.76
| Professional | | $52.32 | $66.30 | $173.76 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $293.00 / $293.00 / $3,239.00
| Facility | | $293.00 | $293.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $46.43 / $139.09 / $175.37
| Professional | | $46.43 | $139.09 | $175.37 |