- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $385.00 / $385.00 / $385.00
| Facility | | $385.00 | $385.00 | $385.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $118.61 / $118.61 / $118.61
| Professional | | $118.61 | $118.61 | $118.61 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $14.23 / $14.23 / $14.23
| Professional | | $14.23 | $14.23 | $14.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $200.00 / $500.00
| Professional | | $150.00 | $200.00 | $500.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $118.61 / $132.84 / $299.33
| Facility | | $118.61 | $132.84 | $299.33 |