- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $375.03 / $502.28 / $502.28
| Professional | | $375.03 | $502.28 | $502.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $150.00
| Facility | | $150.00 | $150.00 | $150.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $127.50 / $150.00 / $154.50
| Professional | | $127.50 | $150.00 | $154.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $150.00
| Facility | | $150.00 | $150.00 | $150.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $154.50
| Professional | | $150.00 | $150.00 | $154.50 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $184.80 / $456.74 / $496.00
| Professional | | $184.80 | $456.74 | $496.00 |