- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $165.48 / $165.48 / $206.86
| Professional | | $165.48 | $165.48 | $206.86 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $600.00 / $600.00 / $600.00
| Facility | | $600.00 | $600.00 | $600.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $86.00 / $500.00 / $500.00
| Professional | | $86.00 | $500.00 | $500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $116.22 / $119.00 / $189.94
| Facility | | $116.22 | $119.00 | $189.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $90.00 / $149.46 / $203.11
| Professional | | $90.00 | $149.46 | $203.11 |