- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $31.20 / $350.00 / $350.00
| Professional | | $31.20 | $350.00 | $350.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $154.00 / $164.00 / $286.00
| Facility | | $154.00 | $164.00 | $286.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $52.22 / $52.22 / $52.22
| Professional | | $52.22 | $52.22 | $52.22 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $51.00 / $51.00 / $51.00
| Facility | | $51.00 | $51.00 | $51.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $10.00 / $15.30 / $15.30
| Professional | | $10.00 | $15.30 | $15.30 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $50.00 / $104.50
| Professional | | $50.00 | $50.00 | $104.50 |