- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $300.00 / $500.00 / $1,255.00
| Facility | | $300.00 | $500.00 | $1,255.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $79.52 / $300.00 / $320.00
| Professional | | $79.52 | $300.00 | $320.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $86.55 / $158.30 / $304.89
| Facility | | $86.55 | $158.30 | $304.89 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $84.75 / $84.75 / $84.75
| Facility | | $84.75 | $84.75 | $84.75 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $63.31 / $101.41 / $208.45
| Professional | | $63.31 | $101.41 | $208.45 |