- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $26.31 / $26.31 / $26.31
| Professional | | $26.31 | $26.31 | $26.31 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $655.36 / $819.92 / $1,109.10
| Facility | | $655.36 | $819.92 | $1,109.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $21.00 / $21.00 / $21.00
| Professional | | $21.00 | $21.00 | $21.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $100.00 / $100.00 / $165.00
| Facility | | $100.00 | $100.00 | $165.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $94.00 / $126.00 / $157.50
| Professional | | $94.00 | $126.00 | $157.50 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $27.63 / $75.00 / $75.00
| Facility | | $27.63 | $75.00 | $75.00 |