- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $146.44 / $146.44 / $146.44
| Professional | | $146.44 | $146.44 | $146.44 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $142.40 / $496.12 / $850.81
| Facility | | $142.40 | $496.12 | $850.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.00 / $75.00 / $75.00
| Professional | | $75.00 | $75.00 | $75.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $50.00 / $60.00 / $1,500.00
| Professional | | $50.00 | $60.00 | $1,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $75.00 / $75.00 / $75.00
| Professional | | $75.00 | $75.00 | $75.00 |