- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $186.38 / $232.97 / $443.44
| Professional | | $186.38 | $232.97 | $443.44 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $150.00 / $150.00 / $150.00
| Professional | | $150.00 | $150.00 | $150.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $90.00 / $90.00 / $90.00
| Facility | | $90.00 | $90.00 | $90.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.67 / $271.67 / $512.37
| Professional | | $271.67 | $271.67 | $512.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $271.67 / $271.67 / $512.37
| Professional | | $271.67 | $271.67 | $512.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $284.60 / $372.00 / $372.00
| Professional | | $284.60 | $372.00 | $372.00 |