- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $111.88 / $201.18 / $201.18
| Facility | | $111.88 | $201.18 | $201.18 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $500.00 / $500.00 / $500.00
| Professional | | $500.00 | $500.00 | $500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $43.77 / $43.77 / $72.37
| Professional | | $43.77 | $43.77 | $72.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $44.50 / $44.50 / $53.10
| Professional | | $44.50 | $44.50 | $53.10 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $58.00 / $58.00 / $70.00
| Facility | | $58.00 | $58.00 | $70.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $60.00
| Professional | | $60.00 | $60.00 | $60.00 |