- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $242.10 / $242.10 / $242.10
| Facility | | $242.10 | $242.10 | $242.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $125.00 / $242.10 / $242.10
| Professional | | $125.00 | $242.10 | $242.10 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $51.00 / $60.00 / $62.35
| Professional | | $51.00 | $60.00 | $62.35 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $64.00 / $64.00 / $64.00
| Facility | | $64.00 | $64.00 | $64.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $106.20 / $106.20 / $106.20
| Professional | | $106.20 | $106.20 | $106.20 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $45.00 / $45.00 / $3,000.00
| Professional | | $45.00 | $45.00 | $3,000.00 |