- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $112.20 / $246.23 / $246.23
| Professional | | $112.20 | $246.23 | $246.23 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $139.91 / $161.38 / $634.67
| Facility | | $139.91 | $161.38 | $634.67 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $246.23 / $246.23 / $315.17
| Facility | | $246.23 | $246.23 | $315.17 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $55.00 / $3,900.00
| Professional | | $30.00 | $55.00 | $3,900.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $307.89 / $429.29 / $524.42
| Facility | | $307.89 | $429.29 | $524.42 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $60.00
| Professional | | $60.00 | $60.00 | $60.00 |