- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $162.12 / $162.12 / $202.65
| Professional | | $162.12 | $162.12 | $202.65 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $327.68
| Professional | | $150.00 | $150.00 | $327.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $215.00 / $215.00 / $215.00
| Facility | | $215.00 | $215.00 | $215.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.75 / $510.52 / $510.52
| Professional | | $146.75 | $510.52 | $510.52 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $215.00 / $215.00 / $215.00
| Facility | | $215.00 | $215.00 | $215.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $81.54 / $146.75 / $231.00
| Professional | | $81.54 | $146.75 | $231.00 |