- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $30.00 / $315.00 / $333.00
| Facility | | $30.00 | $315.00 | $333.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $30.00 / $30.00 / $240.00
| Professional | | $30.00 | $30.00 | $240.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $122.38 / $122.38 / $122.38
| Professional | | $122.38 | $122.38 | $122.38 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.00 / $173.00 / $218.55
| Professional | | $106.00 | $173.00 | $218.55 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $152.00 / $152.00 / $152.00
| Professional | | $152.00 | $152.00 | $152.00 |