- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $90.00 / $162.11 / $355.58
| Facility | | $90.00 | $162.11 | $355.58 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $117.46
| Professional | | $60.00 | $60.00 | $117.46 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $101.05 / $101.05 / $101.05
| Professional | | $101.05 | $101.05 | $101.05 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $60.00
| Facility | | $60.00 | $60.00 | $60.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $60.00
| Professional | | $60.00 | $60.00 | $60.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $153.68 / $367.35 / $367.35
| Facility | | $153.68 | $367.35 | $367.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $60.00 / $60.00 / $85.71
| Professional | | $60.00 | $60.00 | $85.71 |