- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.00 / $500.00 / $500.00
| Professional | | $500.00 | $500.00 | $500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $90.78 / $90.78 / $99.85
| Facility | | $90.78 | $90.78 | $99.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $172.67 / $172.67 / $206.17
| Professional | | $172.67 | $172.67 | $206.17 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $56.57 / $69.31 / $103.98
| Facility | | $56.57 | $69.31 | $103.98 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $55.04 / $65.62 / $446.97
| Professional | | $55.04 | $65.62 | $446.97 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $54.40 / $63.04 / $105.62
| Professional | | $54.40 | $63.04 | $105.62 |